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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------- <br /> (Complete in Triplicate) Permit No. :.----.._... <br /> _....._......:......................---•--..........---•-- <br /> h <br /> This Permit Expires t Year From Date Issued <br /> Date Issued :.-�^.7r <br /> f � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein: <br /> described. This application is made in compliance ith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI .. ..... . <br /> ... .. CENSUS TRACT <br /> - - .. . ..... <br /> Owner's Name ......--- ..................•...... Phone ............. ...................... <br /> Address . ....... .. •- - City .. c...........................................I.....• <br /> ✓'� - <br /> Contractor's Name . ...... .............................:....:....License # 1.4, 3.� Phone .............................. <br /> Installation will serve: Residence Apartment House Commercial ❑Trailer Court 0 <br /> Motel ❑Other <br /> Number of living units:___,...... Number of bedrooms _: .-:Garbage Grinder ............ Lot Size .... ....... <br /> -----------•-------- <br /> Water Supply: Public System and name .......---------•••-- _:...--••••-•••-•••--•...............•---•••-•-.----•.....Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan [Q 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: 1No septic tank or' seepage pit permitted if ubllc sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK I ] Size. .�ir_7�_ .��'-�._...._. Liquid Depth ...`.ems.-.................... <br /> Capacity _1a Type _ -_-... .._. - Materials-� - C':..... No. Compartments ..... <br /> Distance to nea est: Well _.__..__ ................_..•.......Foundation ...LQ.. ..._ Prop. Line .:�t.k .......� <br /> LEACHING LINE [�No. -of Lines ........9----------- Length of each line---.--- �._��_�` otal Length �....�I <br /> 'D' Box ... ------- Type Filter Material ._..--a�A......Depth .Filter Material ..._1_1L....................... ......... <br /> Distance to nearest: Well ......sP----------- Foundation ------ --------- Property Line ...4................... <br /> S EPAGE T . [ Depth ....... -_ .134e hetet 4-_-'A./ Number ....... ................... Rock Filled Yes t' No 0,M <br /> Water Table Depth ...........��._.. Rock Size ...f_'/�_.--_/_3_•-v•._-- <br /> ............... .. <br /> Distance to nearest: Well ......._74-1. ..................Foundation ....1.0_147_ Prop. Line ....... ---------� <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# -.-_.-...----------------------------------. Date .............. .•.................) <br /> Septic Tank (Specify Requirements) ..........................•------------------•................................................................--•............................. <br /> 5/ <br /> Disposal Field !Specify Requirements) .... ......-............................................--------- ------- ----------------------------------_----------- <br /> 1 <br /> -------------------- --•-•-..._..... --------------------------•--------•-•--------•------...---------------------------------------------------- ................ ................I....... <br /> -- -1--- ----------------------------------------- -----------------------------­.•- -_-------- •----- —••--••--•--•--.............._.....-----................................................. .4 ' <br /> (Draw existing and required addition on reverse side)- , -- M - <br /> I hereby certify that 1 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 an person in such manner <br />'F Y P p � p y Y <br /> Ei as to become subject to orkman's Compensation laws of California." <br /> Signed -----------•- ---• •... Owner <br /> By --------------- ------ ------ - -------- Title _4 - ......... ..- <br /> Y <br /> t <br /> Jif other than awned <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- . ............... DATE . .....--- -- <br /> BUILDING PERMIT ISSUED -------------------------------------------------- <br /> ADDITIONALCOMMENTS •--- ---•--- -- •-------- --- --------------------------------------------------------------------------•------- <br /> --------------------------------------- <br /> •------------------------------- ._...... :.. _.._ <br /> •-------- ---------- -- -- ------- ----- <br /> Final Inspection b .............................................Date - ..."r ... ..._._..__..........-- <br /> p y: ... _..._.. <br /> EH <br /> 13 24 1"6 V. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> r <br /> t <br />