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Cli w <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit Nd ...:....: .....-• . ' <br /> (Complete in Triplicate) Per "'- <br /> 1 <br /> ........... ....................... This Permit Expires 1 Year From Date Issued Date Issued ........... 7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein i <br /> described. This application is made in compliance with County Ordinance No, 549 and ex• Eng Rules and R lotions: <br /> . ,. <br /> JOB ADDRESS LOCATION �'_ � �,;;:� .�•-- NrS�T�s <br /> Owner's Name _ . .. . .. +._.' ...... <br /> •. . 3 . _ n .............,..... ..... •r- �.� Phone . <br /> Address —31. .- .... ---•- Cit --- <br /> 1 <br /> , <br /> � <br /> Contractor's Named ��.- ...... _ 'ia� -.License - ne .. j. _ =. <br /> Installation will serve: Residence [JAApartment House Commercial❑Trailer Court 0 <br /> Motel ❑Other .......:.................................... <br /> Number of living units:..j.__.._ Number of bedrooms _._#__--Garbage Grinder ._ Lot Size ./.a ... <br /> r <br /> Water Supply: Public System and name ------7-­._.. . .. .......... <br /> ................:.... . ..•Private <br /> : <br /> Character of soil to a depth of 3 feet: Sand W. Silt❑ Clay ❑� . Peat❑ Sandy Loam ❑ Clay Loam ❑ © ' <br /> Hardpan ❑ Adobe ❑ Fill Material .......... If yes,type ................------------ <br /> (Plot .plan, showing size of lot, loc;tion 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 pubic sewer is avalloble within 200 feet,) <br /> [ ] CTANK-1 ] Size... _._ ' Liquid Depth -. a�.--- ---.. <br /> t' , <br /> PACKAGE TREATMENT Capacity� _. -- Type_. Material x..4"1 "?t.t:K a� Compartments _-. ............ n <br /> Foundation J ' __.... Prop. Line <br /> r - <br /> Distance-n:to nearest: Well ... .... ................•__-. <br /> LEACHING LINE [ ] No, of Eines ..,']...:.............. Length of each line...___? Y :yTotck en ' h= . ........... <br /> w� <br /> D' Box <br /> ------------ Type' Filter. Ma �riai-. - ''Depth Filter ,Mdteriol ---•-- ..................... <br /> --Distdnce toowrest: Well . ............. Foundation .....:4�-----A........ Property Line <br /> ' - SEEPAGE PIT [ ) Depth .............:...... . Diameter ............_... Number ..._ ....................... Rock Filled _ Yes ❑ No {D <br /> Water Table Depth ........................-........................Rock Size ................................. <br /> Distance to nearest: Well ................:.......................Foundation ..................... Prop. Line ....................... <br /> REPAIR/ADDITION-(Prev. Sanitation Permit# ............................................ Date ......-........................... <br /> ) <br /> SepticTank (Specify Requirements) _.----------------- ....-----------•---------------••------••-•-••-•-.....------...-• --------•...... '............................. <br /> Disposal Field (Specify Requirements) ............................................. <br /> - <br /> • -----------•---•------------------•---------______.___----------------••- ............................ --------------------------------- ........... i............................-•---•---__-_------- <br /> ................. - ------------ --------------------------------------------•------------------•---•-------------------------------------------•----...__....._._.-_._...---------• --------- <br /> (Draw existing and required addition on reverse side) j <br /> 1 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 lican- r <br /> sed agents signature certifies the following: '. <br /> "I certify that in the performance of the work for which this per Et is issued, 1 shall not employ any person in such manner <br /> as to become,,subject to Workman's Co ensation laws o a�rnia." <br /> Signed . : .. _-::,�°°- xa . Owner 9 <br /> P r <br /> By .. -------------------------------------------=-----------------------------•-•--- Title ............................... <br /> :-- <br /> (If other than owner) <br /> _ __A9_"AAARTMENT USE ONLY € <br /> APPLICATION ACCEPTED BY ....... „". .................. ....................••-••------_. DATE ..... - <br /> BUILDING PERMIT ISSUED ---•---------•--•••••••--••...................•--•-•----. .......................................... DATE .:....:... <br /> ADDITIONALCOMMENTS ............ ...........................,-..................... .......................................................:........................... <br /> ............................... ............ --_. ................................. <br /> . <br /> w <br /> •--------- -- <br /> Final Inspection by: .. -- <br /> ........... . ..•....._Date ..................� ��--.._-----•. <br /> rt. - ..L.. ........... .... .- .. _ ._ . ._ <br /> { SAN JOAOUiA y L' HEAL�`NI�DISTRICT <br /> = 6'13 241 CIA zI-re z u <br />