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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..................................... --------- (Complete in Triplicate) Permit No. .. <br /> ................................................ <br />........................................................ This Permit Expires ] Year From Date Issued <br /> 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 Ordinan e . 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION �r___-•� . . <br /> S� CENSUS TRACT ..............:........... <br /> Owner's Name ......... ...................................................... Phone .............. <br /> Address . City •- <br /> Contractor's Name XP�. K.. ....................License # ..._._...._..___— Phone ........................ <br /> Installation will serve: Residence portment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ............................................ <br /> Number of living units:....,------ Number of bedrooms AM.....Garbage Grinder ............ Lot Size ..................... <br /> Water Supply: Public System and name ______ _______________________________ _______ ----____.............-_-_•......---------------.. --------...Private [�— <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam fl 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 [ ] Size-------------------------------• -•------------ Liquid Depth .......................... k <br /> A. <br /> Th <br /> Capacity ..................... Type .................... Material...................... No. Compartments ...................... <br /> Distance io nearest: Well _...........•.......................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] 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 /> SEEPAGE PIT [ ) Depth Diameter ................ Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ____Rock Size <br /> Distance to nearest: Well .................. ..................Foundation - Prop. Line 0 <br /> REPAIR/ADDITION(Prev. Sanitation Permit ..- <br /> ................................... Dare ..._.....---........... .......... �- <br /> Septic Tank (Specify Requirements}_••••• •• 124Q.... -� .. --------•-•-• P <br /> Disposal Field (Specify Requirements)-�.........�/�.____ _•..... ....... <br /> ` ----------------------------------------------------------------------------------------------- 4• <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 Son 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/syb'ect to Workman's Compensation laws of California." r <br /> Signed _- ...7 -------- =--------------•................................. ----- Owner <br /> BY <br /> - <br /> By .. ..................................................__.-----------• Title ....-------•---•--_.. - . , <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ........-- -- •_-•- --- ---- -•----•....................••.................................. DATE ......Cq.--v�K4-2.�-------- <br /> BUILDINGPERMIT ISSUED .....................•,...................... ............................................................DATE -----_____....._........_ ................. <br /> ADDITIONALCOMMENTS .....................................•••...•••-•....-•----...-----_............._............-----............_....----.-.............................._....-. <br /> --------------------------------•--•••-• •....._...------. -•--- <br /> - -r----------------- ------......- ; <br /> .....................................------------------ ..............•-..---------------------- .............................. ............. .................................•................ <br /> . <br /> Final Inspection by .Date ........:.. ..... <br /> v . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M 7/72.3 ,14 <br />