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Fon OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />...........................•-........:................... - Permit No. <br /> (Complete 1n Triplicate) <br /> .............._.. ....... .._ ... This Permit Expires! Year From Date Issued Issued ......:3 .... s <br /> Applicationis 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 compl`ianpe with County Ordinance No. 549 and existing Rules and"Regulations <br /> JOB ADDRESS/LOCATION .T 2 . ,rt/,l�xt ....5 !�..�........ ...............................CENSUS TRACT ...... ..:. <br /> Owner's Name .. £ 4 �. ..................... ... ........... ..Phone . ,r-. a� ...... <br /> Address ...................... .. . ..:........._..... .,City ...t .:.........._..._..-----....... ........-........... <br /> Contractor's Name .._.a`Y. ..r��.t..7`: . .. ...i ......License # ......................... Phone y7 <br /> Installation will serve. ResidencepfApartment Housefl Commercial OTraller Court E3 <br /> Motel 0 Other................:......:...:.......:.::..:.. <br /> Number of living. unitsr....1...... Number of bedrooms 247v.....Garboge Ander ... .. Lot za . �-.�.K...�Zd <br /> Water Supply: Public System and norne ................................................. .. .r.1.C.l�, c,. . .e,�.`� .PrivcM E) <br /> Character of soil to a depth of 3 feet: Sand E] silt p Gay 0 Peat Sandy loans 0 Gay Loam a <br /> .Hardpan 0 Adobe(9 fill Material ............ if yes, . .......... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on rev_erse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE; TREATMENT .E # SEPTIC TANK tISisa......•........... . ......................... Liquid Depth ......................."--.X <br /> Capadty ................ Type ................ INa#aria,...................... No. Compartments ...................... ). <br /> Distance.to nearest: Well ....................................Foundation ...................... Prop. line...................... <br /> LEACHING LINE [ ] No. of Lines .......................: Length of each line........................... Total Length ..........:.................(1T <br /> 'Q' Box ...........:. Type Filter Material ............... .Depth .Filter Material ............................................L <br /> Distance to nearestc Well ........................ Foundation .........:.........-.--.. Property-Line .......I................ <br /> —, <br /> SEEPAGE PIT E Depth --.. .......... .Diameter ............. .. Number . Rock Filled. Yes I,] No Q <br /> Water Table Depth ................................................Rack Size ............................... <br /> Distance to nearest: Well ................ ..................._..Foundation .............. .... Prop. line ....... ............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...........>.............. ...� . <br /> Septic Tank (Specify Requirementsl......�x; .._ ................................ ...... ......................... ........................... <br /> Disposal Field (Specify Requirements}_ . . ....�.. �— .� <br /> ----------------- -------------•---------------------------- ......-•-•-------•--•----•--...........................---._�•-.. _..` .:. <br /> (Draw existing and required addition on reverse sidel" <br /> I hereby certify that I have prepared this Application and that the work will be don* in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Name owner at Ilcen- <br /> sed agents`signature certifies the following: <br /> "I certify that in the perFormonce 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 Compo tion laws Pf lifornia.' <br /> t! <br /> Signe ....-•------- -----•----------------_----- (4r l .............. Owner <br /> y � � ' <br /> B itle ............... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....:....................... DATE.. � ..�� -7--�--- ---- <br /> BUILDING PERMIT ISSUED ------------------------- .__..- ._ .__.•_- _. <br /> ....•DAT <br /> ADDITIONAL COMMENTS ---••----••-•-••...............•--•--...._.............--•--........_.-._....--•--.........----.._...__._.......__...... ...................._............. <br /> .._.. <br /> -----.._------------------------------------•-----.._-----•---._.._--•------....._..._..........._.....--•----------.....---._..._..._.._....__.._._,-....---------L----- <br /> ----------- ----- .._.. . }� -• -------------•- ................................_ _. ------------..._ ._ <br /> Final Inspection'by: ..C�......................................... Date _-.... ..7 _.._....-... <br /> EH 13 24 1.-68 Rev* 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />