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` FOR OFFICE USE: <br /> ` __._......4... APPLICATION FOR SANITATION PERMIT <br /> ---- <br /> (Complete In Triplicate) Permi <br /> Permit No.>. . <br /> .... This hermit Expires ? Year from Date Issued Date Issued ... ...... ..� <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 with County Ordinance No. 549 and existing Rules and.Regulations: <br /> .SOB ADDRESS/LOCATION �. . ......... ...........CENSUS TRACT <br /> / -o <br /> Owner's Name .l�� G� �./................. <br /> ............ ... . ........ ...Phone <br /> Address . . .....:_... ................ ...... ..........-_......... ........... city ;! 01 .._...........................-.......... <br /> Contractor's Name ---------------------� �. ............License ... Phone <br /> I <br /> Installation will serve: Residence 1­1 ADartmenfi se❑ Commercial []Trailer Court <br /> Number of living units:... ._ <br /> /._._ Number of bedrooms ,_...Garbage Grinder ............ Lot Size ...... yfrte..ct/e-........... <br /> i <br /> Water Supply: Public System and name E .................Private <br /> Character of soil to a depth of 3 feet: Sand b Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loom ❑ <br /> Hardpan p Adobe Fill Material If yes,type <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,%k. must be placed on reverse slde.1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 240 feet,( <br /> PACKAGE TREATMENT ( ) SEPTIC TANK Size....... ....................................... Liquid Depth .......................... <br /> Capacity /.o ...... Type - <br /> 1�.-Cf . Material...Gwrit;.... No. Compartments ....�......... <br /> € Distance.to, nearest: Well .. �� Q . <br /> # .................foundation'.��..... Prop. Line ... ..........,A <br /> LEACHING LINE No. of tin ___._..- `Length of,eaeh line--_... .............. Total Lengthv..... �W ' ` <br /> 'D' Box .. -- I_ Type Fitter MateriaP�_�.*.4epth .Filter Material ...... 1� Pgi. (1� <br /> w , Distance to nearest: Well .���...�. Foundation Property Line ........ <br /> SEEPAGE PIT ( } Depth ------:.-_-....... Diameter ...............'-. Number ............_............. Rock Filled Yes ❑ No ❑ 1 <br /> WaterTable Depth ---------------------- ---------•----- ---------Rock Size -------------------------------- <br /> Distance to nearest: Well .............. ..........`...........Foundation .................... Prop. Line ...................... <br /> .. _ j-, <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ................. '-- ------ Date ...........:...................... <br /> ) <br /> Septic Tank (Specify Requirements( ---- -------------------`---- ....--- --------...........---�------• -•-------------........................... -••-----.._... (� <br /> Disposal Field,(Specify quiy�men s1t------- <br /> ----- ------- ---•_}. . <br /> . <br /> --.....------. . <br /> - --` ._-...................................... <br /> Imo' <br /> G '---------^-...-,-. ------------ -----------= --------------------------------------- -------------- ----`----------------••------ <br /> '� (Draw existing and required addition on reverse side) <br /> j 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 Lecat Heelth.District. Home owner or ilcen. <br /> sed agents signature certifies the following: <br /> - <br /> "I certify that in the mance of thew k far which this permit is issued, 1 shall not employ any person in such manner <br /> # as to become sub= orkm ansat' laws of California." <br /> Signed - ----- -•---------------- Owner <br /> By -------- ---- ------ -- ----------------------------------------------------- Title ---...---------- -------------------------------------------- ........- <br /> f other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 1�. sir <br /> -. 3 .,.,---- .__.,DATE-.:. <br /> APPLICATION ACCEPTED BY - <br /> BUILDING PERMIT ISSUED -•T :_. -------- DATE <br /> ADDITIONAL COMMENTS _..`7 ._ a �' -a.-------•------------------- <br /> ...-- ----------------------------------------------- <br /> FinalInspection -: ..-- -•----..-- --- -----------•-------------- ----.....-----•--...........-----•--------------•-----------._...........----..��._ .................. <br /> py -------•........................................... ..............................Date _. .- ..._'.. -.... .._ <br /> 13 21a 1�f3 ftev. M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />