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FOR oFFlce use: <br /> APPLICATION FOR SANITATION PEAT <br /> I _ <br /> ----------- Permit No <br /> (Complete in Triplicate) <br /> _. ..........:...• . Date Issued <br /> -r--..-,-.;,•-_..:-•-•---•- This Permit Expires 1 Year'From Date Issued <br /> Application is hiareby 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 Regulations: <br /> ✓ � ,-.....CENSUS TRACT ...... <br /> JOB ADDRESS/LOCATIO ......:r> ..e ---•- ..���.... `.....1....................... <br /> ..........:...................................... P <br /> Owner's Name . .�.. . . ..... -. one .... . . ... .................... <br /> _. <br /> Phone .. . <br /> - i,s�...._...... <br /> Address . . .. .... .��`.l .�.��.�it..._ .�. .-... _ ..�.���..'_ .._`�.City .................... .... _.. .�rf.. <br /> Contractor's Name'... :_. �!"` G_.... t- License # J U4�. Phone .............................. <br /> .... ......... <br /> Installation will serve: Residence[Apartment House Commercial OTrailer Court 0 <br /> Motel ❑Other ...'".. <br /> Number of living units:__._ ._..... Number of bedrooms _ ......Garboa Grinder ........ .. Lot Size _0-< -°°- -- ...... <br /> Water Supply: Public System and name .........:......... .................Private Q <br /> Character of soil to a depth of 3 feet: Sando. Silt p Clay O Peat❑ Sandy Loom o Clay loam Gj -- <br /> Hardpan 0 Adobe Cl Fill Material ............. If yes,type............... ............ <br /> {Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an"reverse sfd4j <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer 1a available within 240 feet,# <br /> PACKAGE TREATMENT [ SEPTIC TANK ] Size......................... ... Uquld Depth <br /> CapacityType Material...................... Na. Compartments ....................... <br /> Distance.to nearest: Well ....................................Foundation ....................:... Prop..Line ...................... <br /> LEACHING LINE [ ] No. of Lines Length of each line........................ -. Total Length <br /> D' Sox Type .Filter Material .......Depth Filter Material <br /> F Distance to nearest: Well ........................ Foundation .......... Property Line ........................� <br /> SEEPAGE PIT .[ ] Depth Diameter ................r-Number .............................. Rock Filled ' Yes 0 No ❑E <br /> Water Table Depth ......Rock Size <br /> Foundation <br /> Distance to nearest: Well :------. .................... Prop. Line ............. ......D4 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..................................I..:........ Date ..................................) OD <br /> Septic Tank tSpecify Requirements). ------••-• •--•-----------------•-.-----..--•---------------- .......................... ............._ ........ <br /> Disposal Field (Specify Requirements) .y ..I__ P &41A'-1...�� .�.-.. ..�. <br /> :_.: k .. <br /> --------- ..... .........-------------------------------------------- <br /> -.............................................. ............................ ............. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance wNh.San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local HsaW Dldtrld. Nome ovmor or licen. <br /> sed agents signature certifies the following: <br /> "I certify.that in the performance of the.work for which this permit If Issued, I shall not employ any person In such manner <br /> R as.to become subject to Workman's Compensation laws of California:" <br /> Signed ........................ Owner <br /> By _..._.. �� ---...._•-----....._. Title - .......... <br /> .(If other than owner) <br /> dR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ - ----------------- ................. --•:----- ,-:-,. DATE .....-. . . ..-..:....,,....:::.......: <br /> BUILDING PERMIT ISSUEb .......:....: . .......... --------••--•-•------...---••---•......--•---.................__._.......DATE _-- ....-• <br /> ADDITIONALCOMMENTS ..............:............•----...........------•-•--......................................................................................................... <br /> ------------------ ------------------------------------------------- ..--_-..:----- --------•---------------.........-......................................................------- <br /> •- •----------- ........... <br /> Fi l Inspection <br /> by: --------•--•-•-- <br /> � 'Final.Ins ection b - ---------------- -- ' - Date -�'.-- .- <br /> EH 13.21 1-68 Rev. 5m JOAQUIN LOCAL HEALTH DISTRICT 8/7!i 3M <br /> 1 <br />