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FOR OFFICE USE: - <br /> /�� APPLICATION FOR SANITATION PERMIT q,} <br /> hermit No: --- �: /_U <br /> ------------ <br /> (Complete in Triplicate) <br /> ` This Permit Expires 1 Year From Date Issued Date Issued _. _ -�� <br /> Application is hereby made to We San Joaquin Local Health District for a permit 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 /> JOB ADDRESS/LOCATION -----.- ---------- -----CENSUS TRACT <br /> Owner's Name _ ✓t. r -.N _,e: -_ -Phone -'T - ...._ <br /> ;�.. � �:.. , <br /> Address � - -- --- ------ ------------ City / <br /> `T'� �¢ <br /> t Contractor's Name--��---- ----` -- -------=--------License # LOds-�/__ Phone <br /> ,. <br /> Installation will serve: Residence pgrtmen't House,❑.Commercial: railer Court ',❑ <br /> ,r Motel F-1Other--------------------------------------------- <br /> Number of living units:_.________ Number of bedrooms ___-Garbage Grinder _°___...--_ Lot Size td__X-_-__-��___o_____________ <br /> Water Supply: Public System and name____C . -- - �[ -----------------------�----------------------- ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑Silt❑ Clay ❑ FPeat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ---------^_ If yes,type _______------------------- <br /> f <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![ ] Size _ <br /> _____ ?+ __._ Liquid Depth _- z_``_____..__ <br /> P � <br /> Capacity _____ Type ___ ____ Material___ No. Compartments ___ ——_____________ <br /> Distance to nearest: Well ----______'I------------------Foundation J1& Prop. Line --/4:v---__:____ <br /> LEACHING LINE [ ] No. of Lines ---------/___.------ Length of each line____/_ Q__--- Total Length f-Q-O-________-- <br /> 'D' Box y------ -,_ Type Filter Material __.oma"-&°--Depth Filter Material ___ _---________________________ <br /> Distance to nearest: Well =:'__°--- _____'___ Foundation _______________________ Property Line ____-__._________--.--- <br /> SEEPAGE PIT [ 3 Depth J. _ Diameter ------- Number ---,--- ------------- Rock Filled Yes No 0 <br /> Water Table Depth ------------------------------------------------Rock Size ---------------- -- <br /> Distance e to nearest: Well --------------------------------------- Foundation -------- --------- Prop. Line ...------------------- <br /> REPAIR/ADDITION(Prev.,Sahitation Permit# -------______________ -` <br /> ---------'------------- Date ---------------------•-•----- <br /> -----) <br /> tSeptic Tank (Specify Requirements) - ----------------- -------------------------------- ---------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------ <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 /> `t "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 /> Signe, ---- ------ ---------- --------- Owner <br /> BY <br /> --- Title ---� Q-4 ---------------- <br /> (If other than owner[ <br /> R DE MENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- - - ----- - - ------------------------------------ ------------. DATE =__'2Z--------------- <br /> BUILDINGPERMIT ISSUED --------- ---- -- --- ----- - -- ---------- -------------------------=--------------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS -------- ---- ------- ------ - ---- ------- --------------- ------------------------------------------------- -------------=--------- ------ <br /> --- I----------- <br /> } -------------------------- --------- - ------- --- ------- -- ---- ------------- -----------------------------------: ------------------------------------------------------------ <br /> ----------------------------------------------- - --- - - - ----------- -- - ------------------------------------------------------------------------------------------------------------------------ <br /> --- ----------- ----------------------- -- ------ ---- ------- -- - ---------------------------------------------------------------------- ----------- ---------------------- <br /> Final Inspection by { - Date _..---- ---- ---7 <br /> JO UIN LOCAL HEALTH DISTRICT <br /> A E. H. 9 1-'b8 R . 5M <br />