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FOR OFFICE USE: <br /> PLICATION FOR SANITATION PERNm' <br /> Per No <br /> (Complete in Triplicate) . ............... <br /> This Permit Expires 1 Year From Date Issued Date Issued ... L. 3- <br /> -7� <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI // -5- L � .7 l/- CENSUS TRACT ..._....-.._...-- -.- <br /> -- --- • - <br /> Owner's Name . . ...... � :._........ri..-..._.-.. ....._,...... ............Phone --.................................. <br /> ----- -- <br /> -Address -- ...... <br /> ....-•••-•.........•. ...._... <br /> Contractor's Name ....... <br /> _.License # � �3 Phone .............................. <br /> 'nstallation will serve: Residence ❑ Apartment Ho e•❑ Commercial Trailer Court <br /> s /� Y <br /> Motel ❑ Other _✓. tet ' .-_,_ :f�cr _._-_ <br /> ` <br /> Number of living units:.. ...... Number of bedrooms ............Garbage Grinder ---------- . Lot Size .._-_-Q.v` '`' :.-__. <br /> Water Supply: Public System and name ._ ................... .................... ---- -----_-- ---- ..... Private (J <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK-{ ] Size._.....__................................_... Liquid Depth .......................... <br /> Capacity - --- --- ----- Type .................... Material.--- ------ -- ------ No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. line ...................... <br /> LEACHING LINE [ ] No. of Lines ...... ................. Length of each line............................. Total Length --... ...................... �1 <br /> 'D' Box ----- _.-- Type Filter Material ....................Depth Filter Material _.......................................... <br /> N <br /> Distance to nearest: Well -,-. ------------------- Foundation ..... ..........-------. Property Line . <br /> SEEPAGE PIT [ ) Depth -._ _ -------- Diameter _..------------- Number . .---. _.... .... -_ Rock Filled Yes ❑ No <br /> Water Table Depth ---------------------------------- -----.-Rock Size ---- ----- .. ----------- <br /> Distance <br /> --- -----Distance to nearest: Well ........................................Foundation -------------------- Prop. Line --------_-----_- <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ............................... <br /> Septic Tank (Specify Requirements) --------------_---------- ............ - _.... <br /> Disposal Field (Specify Requir ments) �t� _`:_._:G?....- Gfd , '!.__ - :_-...`_ L'._-._._ - <br /> L' C i0�.r - S-. <br /> __.._............_ ------------- ---- ------.._.----•-------- -- --- <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that 1 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 /> ced agents signature certifies the following: <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 ...... - ------ - \ - - Owner <br /> ty .. . ._.._-...-....... - -... Title . .2.^!... ..'.-...-t1 <br /> - -- <br /> (If other than owner) <br /> _ FOR DEPARTMENT USE ONLY / <br /> _APPLICATION ACCEPTED BY "P------------- •---.............--••--••--•-•. ---......... DATE ..... <br /> BUILDINGPERMIT ISSUED ..•••-... .... .....-•-•-•................................................•......-DATE ..............._................... • ---- <br /> ADDITIONAL COMMENTS .... . ug......+ 4. G�iG..............................-............_.._._................. <br /> --.....--•----------- - -----------•-----•--.....----•-------....--• •----.......---.......-•-•----.....---......_...........--•-•-•--••-•-----............-----••--••---.................._•----• <br /> -- --- --- -- ----------------- ---------•-•----........-•-•--•--..---•----...••••••._...••••--••••-•............---•-..._._......._....•-•--•-•-••••-••--•.........--•---....._..-•----......-••-........ <br /> ---------------------- ....................................................._.- : _. ...._.. ............. <br /> Final Inspection by: . -'�'-•-•--•--------•-- ....................................... . ......................Date ..... � , ........... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />