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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------- <br /> (Complete in Triplicate) Permit No: <br /> 'This Permit Expires 1 Year From Date Issued Date Issued <br /> _ _ _ _ <br /> F------------------------ _ -- - - <br /> Application is hereby mal a to the San Joaquin Local Health Distract 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/ CATION .- ---V3--��-------(..�--,----- / �.�---------------------CENSUS TRACT -------------- -------.._.. <br /> Owner's Name ----- - - ---------------------------------- <br /> � 1 <br /> Address --------- I � City. ' U G <br /> Contractor's Name ---- tl _ ---------Licer'se # —Ala?_�QPhone -----------_-----•---------- <br /> f �j------- ---- s <br /> Installation will serve: i Residence EKpartment House❑ Commercial E]Trailer Court I❑ <br /> ? Motel❑Other --------------------- <br /> ° <br /> Number of living units:_'. --- Number of roo s __-"_Garbage Gr' deror�Z) Lot Size -_---___"----"---------------------------- <br /> Water Supply: Public S stem and name --"" """"-" _�_., ____�------ ----------"""--""Private ❑ <br /> l " <br /> Character of soil to a depth of 3 feet: Sand'[] ti Silt 0 Clay eat❑e };Sandy Loam ❑ Clay Loam .0 <br /> J <br /> Hardpan ❑ Ad`obe ill Materials"_ If yes,type ____________________________ <br /> (Plot plan, showing size.1Eof 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`p€fmitted if public sewer is available within 200 feet,l <br /> PACKAGE TREATMENT {: ] SEPTIC TANK`{ ] Size-------------------------!---------------------- Liquid Depth -._------------------._-- <br /> apacitY -------------------- Type ---------�'-------- Material--- -- No. Compartments -----------------:.... <br /> Distance to nearest: W11 _�__�x_---__"-_-Foundation --------_-------"---- Prop. Line ---------------------- <br /> I � � \ f <br /> LEACHING LINE [ ] 'o. of Lines ----------------------"Length.of each line----------------- <br /> :V <br /> __-_________ ----- Tota! Length -"----------.--.__-._-"._--- <br /> : E .� N <br /> `D' Box ------------ Type Filter Material,t-_--�+- ------Depth Filter Material -------------------------------------------- <br /> !ll 1 <br /> Distonce to nearest: Well "______---""_-----_----_ Fo'bi ndation ------------------------ Property Line -----------------_-- <br /> SEEPAGE <br /> -"""-" " _-SEEPAGE PIT Re th " Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth -------------------------------------------- - Rock Size -------------------------------- , <br /> Distance to nearest: Well ------------------------------`- '-rFoundati n -------------------- Prop. Line ------------ --------- <br /> I REPAIR/ADDITION(Prev. Sonitation Permit ` _-"'__.________"._ _6--"`Date ------------------------------ <br /> p1 1 01( <br /> Septic Tank (Specify ReIquirements) ------------ -------- ----- - - -------------------------------------- <br /> Disposal Field (Specify! Requirements) - -'------ -? --------------------------------- <br /> I il' <br /> ' ------------------------ ----------------I---------- '----------------------------------------------------------------------------------------- -------------------------------------- <br /> I (Draw existing and required addition on reverse side) j <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 an person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------- ------------------ I - Owner <br /> BY - -----------------------"1!: - -- - ------- � Title <br /> ------- --- ------------------------------- <br /> (If otherr; owner) <br /> FOR DEPARTMENT:-`USE <br /> APPLICATION ACCEPTED;BY - le `� - - _---------------------. DATE -----`� r" -.9' `�--------------- <br /> BUILDING PERMIT ISSUED ------ ---------------- ----- ------ --- DATE ------------------- <br /> --------------- - <br /> ADDITIONALCOMMENTS ------------------------------------------------ ------- ::.. ----------------------- ----------------------------- ----------•----I----------- <br /> - <br /> ----------- --------------------------k- ------------------ -------------------�'r" "--ate----- ------------- _ --------------------------------- <br /> = - ---- - --- ------------------------------------- ------- ------------------------- <br /> ------------------------------Fnal Inspection by: -- ,:.2��-- ------------------Date -.-__-- --� .� <br /> SAN JOAQUIN .LOCAL HEALTH -DISTRICT = <br /> E. H. 9 1-'68 Rev. 5Al1 <br />