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FOR OFFICE USE: <br /> APPL115MON FOR SANITATION PERMIT <br /> --------------------------------------------------------- (Complete in Triplicated Permit No. ._7.1:r���____. <br /> _ <br /> ______ ______ _________________________ ____________ This Permit Expires 1 Year From Date Issued Date Issued --4/777L-___. <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 ompliance with County Ordinance No. 549 and existing Rules and Re ulation <br /> JOB ADDRESS%LO SIC} " <br /> �' <br /> Owner's Name ____ ----- -.Phone <br /> Address � <br /> 3.3 4g_- -- -- --- - - - - - ---------------------------------------------- City _ �-- ---- _ - ----------------- ----- <br /> Contractor's Name ---------- -----------------------------------------------------------ticense # --- Phone '._:-:-;- <br /> Installation will serve i nce ®`Apartment House❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑Other ------------- --------------------- ------ <br /> Number.of living units_____________ Number of bedrooms -.2------Garbage Grinder 4 /--- Lot Size _1,-j041?0t5;o_2A? ___________ <br /> Water Supply: Public System and name ------------------- ---------------_-----------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay Ej Peat❑ Sandy Loam :X Clay Loam ❑ <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,) Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[] Size-/ - ` Liquid Depth --------------- <br /> , <br /> Capacity/;r.ft_._____ Type _C44t----- Material-4 -------- No. Compartments -- ___ }. <br /> Distance to nearest. Well ---irk--------------------------Foundation ----/'b........... Prop. Line ._!F�_______________ <br /> LEACWING LINE ,[ ] No. of Lines __.__�--._.__________ Length of each line____a1 Total Length --- -+�________________ <br /> �oq <br /> 'D' Box _ ___ Type Filter Material �_�__________Depth Filter Material --- 7__ --------_--------------.....___-_ <br /> Distance to nearest: Well ______________________ Foundation ------------------------ Property Line- __-_______________-_-___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number Rock Filled Yes ❑ No i❑ <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) -------------------I---------------------------------------------------------------I-------T--------------------T_-------------------------- <br /> Ii <br /> DisposalField (Specify Requirements) --------------------------------------------------------------------------------- --------------------------------------------------- <br /> 7 <br /> ----------------------- ----------------- JII <br /> 1 <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 /> "1 certify Yrt in the performance of the work or which this permit is issued, I shall not employ any person in such manner <br /> as to be sub' t to Wor ek- <br /> o tion laws of California." <br /> w _ <br /> Signed _ _ - Owner <br /> By -----------------------------------------------------=--- - ----------------------------- Title ---------------------- <br /> ------------- ------------------------------------------- ----- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY _.__ �_ 7 _ ` <br /> - -- --------- -=---------------------- ------------------------------------- DATE ----Y---- ----�---------------------- <br /> BUILDING PERMIT ISSUED.-------=---------- --------------------------------------------------- -------DATE -----------------------------------------`- <br /> ADDITIONAL COMMENTS.--------------------------------------------------------------------------------------------------------------------------------------------•- ------ <br /> - -----------•---- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- f} -------- ---------------- <br /> �} <br /> Final Inspection by: -----1�1__ �C !_________________________________________________ ________________________Date 1q_'1----. --7I-------- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />