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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 1 <br /> ............ ................................. <br /> " IComplete In Triplicate) Permit No. <br /> ................••--........................ <br /> Date Issued <br /> This Permit Expires f Year From Date Issued , <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to construct and `.install the work heroin <br /> described. This application Is made in compliance with County Ordinance No. 549 and existing Rules and Regulations:JOB f <br /> Owner's ':Name <br /> .. ... . ........................... ..1.�. ........_............................................CENSUS TRACT .:....................._. <br /> Name _....... .�. .,fd fI✓._ � 1��a�'✓ ..................... ................. ..........Phone <br /> Address .a'...........- ..... ..la.- .Q.. . je. .16......�.............................� -._..Ci ......... !t. _........................................ <br /> M <br /> Contractor,'s Name ..........Z? 1?2_ ....................................License ih .........,.............. Phone -----•--._......__ ........... <br /> Installation will serve: Residence Opartment House Commercial❑Trailer Court ❑ <br /> Motel []Other <br /> f living units:_..)----- Number of bedrooms ..Garbage Grinder ............ Lot Size ... .G- :.......:....... , <br /> Number a <br /> WaterSupply: Public System and name ................................._....................._........._....................---.......-----------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Slit 0 Clay ❑ Peat❑ Sandy Loam day Loam ❑ <br /> OSS <br /> +' Hardpan❑ Adobe❑. Fill Material ............If yes.type............... ............ . <br /> rPlot plan; showing size of lot, location of system In relation-to wells, buildings, etc. must be placed an reverse side.) <br /> NEW INSTALLATION:. (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE"TREATMENT- I ] SEPTIC TANK f I Size _ <br /> .....-------•................................... Liquid Depth .......................... <br /> : <br /> : Capacity.. ...... ... Type .........� .. <br /> ..------. Material............... ..... No. Compartments <br /> • Distance to nearest:. Well ....................................Foundation ...................... Prop. Line ...................... f <br /> TEACHING LINE { I No. of Lines ..................:....: Length of each line............................. Total Length ........................... <br /> D' Box ............ Type Filter Material ....................Depth Filter Material <br /> ........................................._. * a� <br /> - , 'Distance to nearest: Well......................... foundation ........................ Property line ........................ <br /> SEEP�AG,E PIT Depth%� ...:............... Diameter ................ Number ............................ -Rock Filled Yes ❑ _ No ❑ <br /> Water Table Doi th................................................Rock,Size ...................... .......... <br /> Distance to nearest: Well ........................................Foundation ................ ' Prop. Line ........................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit -----••-:.................................. .Date ....................................I <br /> Septic Tank (Specify Requirements) ...... . .... .y ............ <br /> Disoosol Field (Specify Requirements' ..... .. .... .r!G+. C -:..1�5...r...._ �[. .x, .....°...... <br /> ...-- ---•.... ...................................•..-----_.. .,�Pl ................................................... ................................ <br /> -•......... .................................... ...------..................••---•-...._._...... _ ...__--•--....---•........................................................•-•--........... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with Sar Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District.,Home owner or Ilcen- <br /> sad agents signature certifies the following: { <br /> "°I certify that.in the performance'of the work for which this permit is issued, I shall not employ any person in such mann ,L <br /> as to becomeAsubto Workman'. Ca a tion laws of California." <br /> Signed ---• .. ... .... ................................ <br /> By <br /> Owner' <br /> Sy ............ ............. .........-----•............................_... Sitle ......................:................................................. <br /> .�. .;,� (If otheuthan owner) _ <br /> •-,....,'-- FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .........--Vd ..........................................r................................... DATE .... ...$1-.ca .7 ...........: <br /> BUILDING'l�PERMIT ISSUED . _. __ <br /> ADDITIONAL COMMENTS .... ............................................. ........................... . ._.. ......_ ...DATE= - - - <br /> t <br /> .......... .... ... ...............................•---•-•.................... .......... . .-. ............................................. s <br /> _. . . .......................... ..._....... ........... ---•-------•-•.....--- •...................... ........... <br /> ........... ....... ........................ . <br /> final'inspection by <br /> ' C� :.. ... .............................Date ... ............. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3MC.3 <br /> Z <br />