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rVR vrriL.0 il5t: <br /> APPLICATION FOR SANITATION PERMIT <br /> ...-----••. { <br /> #Complete to Triplicate) reit No: .: •.: ..-�.---.._ <br /> ........- -------- -- ---- Permit. <br /> �_.._... This Permit Expires I Year From Date Issued Dote 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 application is made in compliance with County Ordinance No. 5:49 and existing Rules and Regulationst <br /> JOB ADDRESS/LOCATION ..-- ......-. .. --.. . ........... ...............CENSUS TRACE' --.-...................... <br /> Owner's Name ........... .. .......... ...........Phone <br /> Address <br /> License � ...................... <br /> Contractor's Contractor's Name ---- . `--.. aij--------- <br /> ----••-- #�-��•��1...-. Phone - •� <br /> Installation will serve: Residence f Apartment House C] Commercial(]Trailer Court 0 <br />� :Number of living units:_--. Motel.[]Other -------------------•---•-•-------••-- --• -- <br /> 9 -_-- Number of bedrooms ---Z...Garbage Grinder ------ ---- Lot Size._-- Z�-.----•- -- •-- - <br /> Water Supply: Public System and name -------------------------------- <br /> Character of snit to a depth of 3 Private❑ <br /> -- ------------------------------------------feet:. Sand Li Silt(] Clay 0 Peat❑ Sandy Loam (] Clay Loam <br /> Hardpan 0 Adobev Fill Material <br /> ............ If yes,type............... ........ <br /> :.... <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: <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ) SEPTIC TANK SizeLiquid Depth .. <br /> I <br /> ..................._-- <br /> ------------------------------------ <br /> Capacity ------ Type -------------- Material.----,-,-------------- No. Compartments ......................-- <br /> Distance to nearest: Well ----=------------------ -----------•foundation ---....-_-----.•_-_-- prop. Line ....I................. <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line--------------- .-.--... Total Length <br /> .............. <br /> D' Box ........... Type Filter Material --------------------Depth Filter Material ...--......-. <br /> Distance to nearest: Well .............. Foundation ................. Property Line . .. <br /> SEEPAGE PIT ( ). Depth --.--•-....- <br /> . ^.,. -------. Diameter ---------------- .Number ...................... Rock Filled Yes <br /> 0 <br /> Water Table Depth ..........................-------- Size ................ <br /> Distance to nearest'-, Well -----•----------------- ----------------Foundation .................... Prop. Line -=----• ................. <br /> REPAIR/ADDITION#Prev. Sanitation Permit# .................. -..------ Date .-.-•--........._. - - <br /> --..... <br /> Septic Tank (Specify Requirements! ...... CGt r..."'"...... ed'. <br /> Disposal Field (Specify Requirements) ...................... <br /> ----••-----•------------------------------------- ........-----------------------------------------------------------------------------------------1 <br /> .--------------------------- . <br /> ------------------------ ----------------------- ----------------------------------------------------- ------------------------ ....... ------------------------ <br /> (Draw <br /> ----------- -- <br /> (Draw existing and required addition on reverse side) s <br /> I hereby certify that I have prepared this application and that the.work will be done In accordance with San .Ioagvin <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: F <br /> "I certify that in the performance 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 Compensation laws of California.,, <br /> Signed - -- - 1_.. - Owner t <br /> By - -- d�. ;Citlecc�Gt�t <br /> ..------ <br /> (If other than owne <br /> FOR DEPARTMENT US ONLY <br /> APPLICATION ACCEPTED BY --------------------- '-- _ <br /> - -- -- --•-------- ......-..DATE .��.:..7�- 7 c'�-----'... <br /> BUILDING PERMIT ISSUED --..- -------- -- -------- ------------ •-------.-DATE -------------- - <br /> ADDITIONAL COMMENTS .-..- <br /> ---- <br /> ::::: ---- 12-` a� ----- - -------------- -- - <br /> --------------------------------- <br /> ...-_..... <br /> SA <br /> --------------------------------- ------------------- - ----------------------------------------- <br /> FinalInspection by: .4v� <br /> �����...------- ........ ..... .. ......Date ..��- - -.Eli 13 2� 1-6� . - .. I <br /> N JOAQUIN LOCAL HEALTH DISTRICT 874 <br />