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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ( <br /> Permit No. .---�`-- <br /> Complete in Triplicate) <br /> ------------------------ ---- - -------------- <br /> - <br /> ---------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued 11r115� 6) <br /> Application is hereby made to thet-S-d.�oaquin Local Health District for a permit to construct and install the work herein <br /> described. This app)catiorj'- t­made in compliance with County Ordinance No. 549 and existing 'Ru! s and Regulations: <br /> j <br /> - _-l <br /> --JOB ADDRES ----- --------- -- ---� <br /> 's -Name Phone <br /> � <br /> Owner ------- <br /> 17 � . ------------• CityAddress � � Phone ----d------�------ <br /> ` <br /> ► <br /> t <br /> Contractor's Name License # <br /> Installation will serve: Residence ❑ Apartment House❑ Commercialfrailer Court ;❑ <br /> Motel ❑ Other-------------------------------- ----------- <br /> Number of living units_____________ Number of bedrooms ------------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 ❑ Clay Loam- <br /> _. Hardpan E] ---;Adobe❑­5,Fi,I,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.) y <br /> NEW INSTALLATION 1No septic ankocseepage pit permitted if,public-'sewer.is available within 200 feet,] <br /> PACKAGE TREATMENT [ SEPTIC TANK J <br /> Rs - Size___�/-_/ao _X4_X.�_. ' ------ Liquid Depth ---+-_®__________ <br /> Ca acty' �d.0_ ___ Ty?e ` * _ Materialw— 'No., Compartments - -- -------- <br /> >--- <br /> 01 <br /> Distance to nearest: Well --------------------------Foundatio' n Prop. Line ------- __________ <br /> �- <br /> -LEACHING LINE X No. of Lines ________________________ Length of each ;line 7S 7�S-__ -_ Total Length ---l_S00____:__-_ _* <br /> QQ <br /> 'D' Box ----/.--- Type Filter Material ado <br /> S/ORPG�Depth Filter Material I---___'2451_ _______________________ , <br /> Distance to nearest: Well f _______ Foundation ----X ---------- Property Lite _ ----------------- <br /> SEEPAGE <br /> __-------SEEPAGE PIT `�' Depth Diameter �---_--__ Number ----------�--_--_- Rock Filled Ye� No U <br /> _ ,, . .i i- <br /> '�j <br /> Distance toWater lnearest: Well --��__`____�__________._Foundation -----U _ <br /> 4__-- _- Prop. Line _S_±__ !!__.._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------- --------------------_) <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ----------:------------- - <br /> DisposalField (Specify Requirements) --------------------------------------------- --------------------------*--------------------------------------- -------------------� <br /> ------------------------------------------ <br /> ------------------------------------------------------------- <br /> ----------------------------------- ------------ <br /> - ------------------------------------------------------- -------- ---------�6 <br /> (Dray✓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 /> "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 be a su ie$t t5t orkma s Compensa io Iaws of California." <br /> f Y. <br /> Signed e --- �---- ---------------- caner <br /> By -------- -------------------------------- t Title ----- --------- ------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-_.A_1%_-Z,--------------------------------------------------- ----- b <br /> -- -- � DATE _ ----=_�-- �-�'--------------------- <br /> BUILDING PERMIT ISSUED ---- --- - ---------------------------------------- ------------- -------DATE ------------------------------ ------------ f <br /> ADDITIONALCOMMENTS'----=-- --------------------------- ---- --------- -- ------------------ --------- ------------------------------------ --------- <br /> --------------------- -------------- - - - ---------------- ------------- ---------------------------------------------------------------------------- 4 <br /> �_: } <br /> Final Ins ection __Date ___ 40 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> A i <br />