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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Co <br /> mpl*19 in Triplicate) <br /> ................I........... ................. <br /> . .. ....... <br />.............I..........................................•--. This Permit Expires I Year From Date Issued <br /> 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 ahcation is made in compliance,with County Ordinance No. 549 and existing Rules and Regulations: <br /> afflplw <br /> W& xm <br /> JOB ADDRESS/LOCATION <br /> A/#vCEN'SUS TRACT ...................... <br /> Owner's Name ar__,M jIny A <br /> . . . ........................Phone .................................... CA <br /> Address ---- <br /> ........... .. ...............................city ............. ......... ................................ <br /> Contractor's Name ......... .. . .. so. <br /> .. . ....................................Licen 7 <br /> # Phone <br /> Installation will serve. Residence rApartment House f3 Commercial oTraller Court 0 <br /> Motel 0 Other ........I................ <br /> .................... <br /> Number of living units------------- Number of bedrooms ............Garbage Grinder ............ tot'SI 's <br /> Water Supply: Public System and name ........ <br /> ..........................._..........-•-•--....-.. ..............................................PrIvatep— <br /> Character of soil to a depth of 3 feet. Sand 0 Silt 0 Clay 0 Pact 0 Sandy Loam jj Clay Loom <br /> Hardpan 0 Adobe 0 Fill Waterfal ............ if yes,type............... ............. <br /> }Plot plan, .showing size of lot, l9cation of.,sysfem 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,) <br /> PACKAGE TREATMENT SEPTIC TANKSize ", ..P.................... Liquid Depth ...#................... <br /> Capacity ... .&-�7.... Material No. Compartments ..... <br /> Type ..........I <br /> Distance.to nearest: Well _IPP.......................Foundation ..../0.......... Prop. Line ....'`d......'.......... <br /> LEACHING LINE No. of Lines 'Length of each line. Tota!a Length <br /> 'D' Box ......:..::. Type filter Material ....................Depw,�-Fllter, 'Material ............................ <br /> ................ <br /> Distance to nearest: Well ........................ Foundation ................ ....... Property Line ........................ <br /> SEEPAGE PIT Depth 4 _Cytldoiameter ................ Number <br /> . P-I^ ,:�.>--------- ......... Rock Filled Yes �No (3 <br /> Water Table Depth ....... ............ ...........................Rock Size ,-.,/ ------- <br /> ' <br /> 'Distance to nearest. Well ........................................Foundation Prop. Line ...................... <br /> --- <br /> REPAIRADDITIONIPrev. Sanitation Permit# .................................... ....... Date ............................I <br /> Septic Tank (Specify Requirements) ...... ....................... ......... .............. ..................... <br /> Disposal Field (Specify Requirements) .......... ...... ------ <br /> ---------------------------------- ............................ <br /> ------------ ................. ..............;�...............Z.................................................................... <br /> --------------------­----- ----------------.._....-------------------• -•-•-----­----------- -­_.............-----•••--........:...... <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 do" In accordance with So Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health,District. Home own:-or licen- <br /> sed agents signature certifles the following- <br /> 1 certify that in the performance if the work for which this permit Is Issued, I shall not employ any person In such manner <br /> as to become subLect t Work- -- -n-.s---C--ompenso- n-- <br /> laws--o--f- California." <br /> Signed .......?- . Ow <br /> ner <br /> By ................ ------------------**----------------*---------------------------------------- Title .. ............. ........... <br /> (1f other than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------- --41 ... .... ------- DATE ...... <br /> BUILDING PERMIT ISSUED . <br /> .... .....I............................. ...... ---------------DATE ....... ................... <br /> ADDITIONAL COMMENTS .... ...... ------- - ----------------------------- <br /> ------------------------------ --------- - ------­­ ­ -- <br /> ------------------- --------------------- ---------------------------------- -• -------------- ----- ------ ........... <br /> - -------1------------------- . ................ ............... ----------------__............................___.............................. <br /> ---------------0�. , <br /> Final inspection by, ?-------------------------------- <br /> ...... ------------_-__................Date,.��.A.....2S......... .......... <br /> -------- ---- - - ------- ----- ­ <br /> --------*,--,-*-----------------*.........*-------- ----------- <br /> EH 13 24 1-68 5m SAN JOAQUIW'LOCAL HEALTH DISTRICT 8/7h 3M <br />