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FOR OFFICE USE: <br /> �, 3Q ? 9,7 //I:: sy �_ -,APPLICATION FOR SANITATION PERMIT (� <br /> Permit No. d-- Fv <br />' (Complete in Triplicate) <br /> ---------=------------------------------------ <br /> ------_--- This Permit Expires 1 Year From,Date Issued Date Issued <br /> Application is hereby made to the 'San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> s <br /> JOB ADDRES CATION __ __ -_ --. - �. CENSUS TRACT ______________________--- <br /> Owner's Name., . - � Phone ------------------------------------ <br /> Address --- ----- - - -------------------------- City -- lt/-- - ---------------- -- ,----- C�f <br /> i - -- <br /> Contractor's Name - - -- -- --------------=--------License # Ione -------•-••----- <br /> Installation will serve: 'Residence ❑ Apartment Nouse^❑ Commercial :❑Trailer Court <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:-____. _. Number ear oms - " �`" 11-e <br /> G e Gr' Lot Size � __ ----------- <br /> Private <br /> I Water Supply: Public System and name ------- ------------ ----- -� �-�----� "gym ❑ <br /> k Character of soil to a depth of 3 feet: Sand'❑ Si t C y .❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material _ If yes, type _-_------------------------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Size------------------------------------------ ----- Liquid Depth -----------------_------- <br /> Capacity -------------------- Type -------------------- Material---------- - --------- No. Compartments ------------_------- (A1 <br /> 'f Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line _---------_-_-------•- <br /> ! LEACHING LINE ,J I No. of Lines ------------------------ Length of each line--------------------- ------ Total Length -----------.----.----------- <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material __---.--_____---- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ------------ ----------- <br /> r <br /> Sl"EPAGE PIT [ ] Depth --------------------- Diameter ----------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ \4\ <br /> Water Table Depth ---------------=--------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well --------- .-------Foundation -------------------- Prop. Line -----------_-------- <br /> REPAIRfADDITION(Prev. Sanitation Permit# ---------------------------- •----------- -- Date ----------------------------------) <br /> Septic Tank {Specify Requirements) -----=---- ----------- -- ='-----------=-- ---- <br /> �p� <br /> Disposal Fi Id (S e ifs Requir ments�f �-�` <br /> - �� --- <br /> - � --------------- ----- -------- ------ ------ <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 San Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed 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 manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------- ----------------------- ---------- ------. Owner <br /> [ BY - --------- Title --- -!�/- - .✓ <br /> (if of er owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --. -_-__G!�------ ------. DATE ------�-"-Z`�- ---------' <br /> BUILDINGPERMIT ISSUED ----- -- -------- ----------------------------------------- ------------=---=--------------DATE ------- ----------------------------------- <br /> ADDITIONAL COMMENTS ----- -------------------------------------------- - -------------------------------=-----------------------=----------- <br /> - -- ----------- <br /> ----------- -- <br /> --------- ----------------------------------------- ----- ------------------------------------------------------------------------- -------------------- ------------------------------ <br /> --------------------------------- <br /> -------- <br /> -------------------------- - ------ <br /> Final <br /> ----Final Inspection by: ___ _ Date --_. --^ d -7 <br /> -------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' E. H. 9 1-'b8 Rev. 5M <br /> 1 <br />