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.�� <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ..7s..11.�/:S <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 <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulation: <br /> JOB ADDRESS/LC7CAT10 �_�`� o' <br /> f� ° <br /> Owner's Name ..... _� pp --- CENSUS TRACT .......................... <br /> Phone ... ............................. <br /> Address .. .... ... <br /> .. ....ted. <br /> Contractor's Name . <br /> ._ _- <br /> .License <br /> #01" -. V�r7-- Phone r! 6) <br /> Installation will serve: -4 Residence XApartment House❑ Commercial ❑TfailerCourt ❑ <br /> Motet [] Other . ......... <br /> q ------ <br /> Number of living units:.. Number of bedr oms -.2---- Grinder .�_ -� lot Size ..._� <br /> Water Supply; Public System and name `� ./�.�.---•. <br /> .............. ....................Private <br /> Character of soil to a depth of 3 feet: Sand Ar Silt❑ Clay ❑ Peat❑ Sandy Loam C] Clay Loom ❑ <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,J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK .�0 <br /> Size r <br /> `- - �..... Liquid Depth .-- .._� <br /> Capacity/-2a 6X/Type . .Material.. No. Compartments __. ... N <br /> Distance to neatest: Wellr <br /> 5�.._-- -- --------------Foundation ..�ll,� p, ` � f_ <br /> ....... Pro tine _..�._.....__._. <br /> NE No. of Lines Length of each line p ". , .... Total Length r <br /> LEACHING LINE 9 -,A1 a............. <br /> D' Box .. .� Type Filter Material -lea <br /> ------Depth Filter Material .. <br /> r. <br /> Distance to nearest: Well _. d �- C <br /> . ............ Foundation �Q._....._...... Property Line .... <br /> GE PIT [ ) Depth ..... . Diameter tv <br /> ----------- <br /> SEEPAGE Number ........ - ... Rock Filled Yes ❑ No l <br /> Water Table Depth -._...................... --..Rock Size .....-................... <br /> Distance to nearest: Well ------ -------- ----------- ------------Foundation ..... ...--. ....... Prop.-.-- Line ----- jr <br /> REPAIR/ADDITION(Prev. Sanitation Permit -...--_----- <br /> �# _-. N <br /> ....... ....... . . �---- Date ------ •----...-------------------) <br /> Septic Tank (Specify Requirements) ..- .-- <br /> Disposal Field (Specify Requirements) .................................. <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 fecal 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 net employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed . . Owner <br /> Title <br /> f of er t on owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> BUILDING PERMIT ISSUED DATE . <br /> ADDITIONAL COMMENTS .. . ............ <br /> .... .---.- .. ...DATE . ....... <br /> ............... .... ---- ....... <br /> .............. <br /> FinalIns ection b --- -------------L...--- _.._....._......-..._.....---- ----- <br /> Inspection Date, . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 1-3 241-'68 Rev.SM ��-� �� 69 <br />