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,FOR OFFICE USEI, APPLICATION FOR SANITATION PERMIT <br /> -------------------------- Permit 110: <br /> (Complete in Triplicate) JJf� 3 <br /> ------------------_- This Permit Expires 1 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 /> JOB ADDRESS/LOCATION � -------------------------------- - --------- -------------CENSUS TRACT --------------•----------- <br /> Owner's Name .--- f y�f =c�'� ~'------------------------------------------------------------- ---------------------Phone ------------------------------------ <br /> ---- - n --- •-------------------- - CitY <br /> ------------------------------------------- <br /> AddressContractor's Name ---------------------License # 1, Phone' f� l <br /> . ' <br /> Installation will serve. ResidenceXApartment House❑ Commercial :❑Trailer Court 1Q <br /> Motel ❑Other ------=----------- ------------------------ <br /> Number of living units:_______ Number of bedrooms --�----Garbage Grinder Lot Size g'e, -- ------------ <br /> Water Supply: Public System and name - A(2 ...... /- --- t « - -------------------- Private ❑. <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Gay Loam ❑ <br /> Hardpan ❑ Adobe 0 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,) Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ----------.--------------- \ <br /> Capacity -------------------- Type -------------------- Material----------- No. Compartments ------------------ <br /> Distance to 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 -------------------------------------------- i <br /> Distance to nearest: Well ------------------------ Foundation -------- ---- Property Line, --_----------.-.--.----- <br /> SEEPAGE PIT [ ] Depth --------- ---- .Diameter ---------------- Number _---- Rock Filled Yes No <br /> ----- Number ---------- ---------- ❑ C3 � <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----------.-......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------.-.----_------------.-----) <br /> Septic Tank (Specify Requirements) -------- ----- ------------ -------- � <br /> Disposal Field (Specify Requirements) -_- - - --- �---- �'- �! _'��---- - ---- ,� - <br /> - , - <br /> Y '------------------------------------------------------------------------------------------------------ <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 Son Joaquin Local Health District. Horne 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 subject to Workman's Compensati laws of California." <br /> Signed -------- --- ---- Owner <br /> i <br /> SY --------- ---- ----------------- �. - . . - ---------------------------- Title <br /> (If oth t an owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..- DATE ----_ <br /> BUILDING PERMIT ISSUED ------------------------ - ---- -DATE <br /> ADDITIONALCOMMENTS --------------------- -------------------------------------------------------------------------------------------------------------=--------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---v ---------------------------------------------------------------------------------------------- <br /> 6 �,--------------------=------- <br /> g. Final Inspection by: WV -----------Date �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F H 9 1_'f,8 Rev_ 5M <br />