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FOR OFFICE SEr1V"7: <br /> i O <br /> APPLICATION FOR SANITATION PERMIT <br /> .................. <br /> ---- (Complete <br /> (Complete In Triplicate) <br /> .......................... <br /> Permit Na <br /> _4!�• •••-•-•••.. . i <br /> ........................ ................................ This Permit Expires 1 Year From Oats Issued dada Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work here' <br /> described. This application is made in compliance wit my Ordinance No. 549„ndxis sting R I$s_s�nd Re lotion <br /> JOB ADDRESS/LOCATIO _..... ..... .. %'� <br /> � -...... .. CENSTRACT .. <br /> p <br /> Owner's Name ............. sf . . . .........--'...................---................... Phone ... c4-:. �, �..._. <br /> Address .......................... � City <br /> Contractor's Nome --r�_I .�-•__= :t=_-•- ---. --- _.License # ........................ Phone IP <br /> Instollation will serve: Residence NApartment Housefl Commercial❑Trailer Court <br /> Motel ❑Other------------------ .................... <br /> Number of living units:..... Number of bedrooms------Garbage Grinder ............ Lot Size . _ . ._ _. ............. <br /> Water Supply: Public System and name ....-..................................................._..:......r..........................................Private <br /> Character of soil to a depth of 3 feet: Sand o Sift❑ Clay ❑ Peat❑ Sandy loam o Clay Loam 2C <br /> Hardpan Adobe)K,Fill Mcterlal ............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 /> r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK j . Liquid Depth <br /> Capacity . Material.................. No. Compartments 'r <br /> Distance. to nearest: Well ....................................Foundation ...................... Prop. Line ......................� <br /> LEACHING LINE [ j No. of Lines ........................ Length of each line....--_----....----------- Total Length ............................ uti <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 ...................... <br /> REPAIR/ADDITION{Prey. Sanitation Permit# ...........--------------------------------- Date ............ ..................... <br /> Septic Tank (Specify Requirements) ��.-------•------- ---------------------- K ----•-------•...._..••-------•...----------•- --•-----...........� <br /> Disposal Field )Specify Re irements) ==IR ... <br /> .. . <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 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 pe ante of the work for which th s ermit is issued, I shall not employ any person In such manner <br /> as to beco sable an s Co pensat' n laws o Ca arnla. <br /> Signed `- _ •' --- <br /> BYOLLf_. . <br /> Of other than owner} Title <br /> _ <br /> FOR DEPARTMENT USq ONLY <br /> APPLICATION ACCEPTED BY -----------------_1--------- DATE .-.. 70-------- <br /> BUILDINGPERMIT ISSUED --------------------------- ......................... I ....................................DATE ------------•-----_ ....... ........ <br /> ADDITIONAL COMMENTS ---'....... ......................."-... <br /> ----•-•---- ------------.....-•--•----------------••--- - ----••-----------•--•---•-•---•-----------------•-----•----•----•-'-- ............._."-"_....-"..._.. <br /> ---------------------------- ---- --------- "- ..... -- ------ <br /> Final Inspection by. - ._Date a.y. �. <br /> 13 2 � v• SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />