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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (complete in Triplicate) <br /> . .-•-----•----------- <br /> --------------­*--------------------*........... This Permit Expires 1 Year From Date Issued 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIP ---------------..CENSUS TRAa ..............­­....... <br /> , <br /> Owner's Name -*.Lop------ -- -- ........................ .........._........Phone <br /> 16.. 0 <br /> Address --- -------------------- City ._ .... .. ...................... ......... <br /> op ........ ----------- ......License Phone <br /> Contractor's Name ...44, r <br /> Installation will serve: Residence 0 Apartment House Commercial OTrailer Court 0 <br /> Motel 0 Other ------ --14-M_ Z� <br /> Number of living units:...__ .... Number of bedrooms ------) ---Garbage Grinder ---_------- Lot Size ........ --------- <br /> Water Supply: Public System and name _-- ------- --------------------------- <br /> ----------—-------------------------------------*.............Private <br /> ct <br /> Charaer of soil to a depth of 3 feet.. Sand 0 .Silt 0 ,Clay El 'Peat 0 .Sandy Loam0 . Clay Loarn ❑ <br /> Hardpan 0 Adobe 0 Fill M6teriol ............ If yes.type-----_-------------_----- <br /> .(Plot plan, showing. size of lot, location of. system In relation for 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 /> [4: <br /> PACKAGE TREATMENT, [ ] SEPTIC TANKM -------- Liquid Depth ---------- <br /> Capacity Type _G.41 ...... Material.�� No. Compartments ........ <br /> Distance to nearest.. Well ----------------_--Foundation ....1_0_ -------- Prop. Line —No. of Lines ---------- Length each line -------- <br /> LEACHING L(NE <br /> ea Total Length ............0 <br /> 'D' Box -----t!�� Type Filter Material 4of 1na.._....Depth Filter Material <br /> i '`---•---I.... <br /> Distance to nearest: Well ------------- Foundation ....1Aft--------- Property �Line � I- <br /> ............. <br /> -..SEEPAGE PIT Depth -------------------- Diameter ...........-.-- Number -.---------------------_----• Rock Filled Yes C). No 0 <br /> Water Table Depth ---------------------------------- TT <br /> --------------Rock Size ---------------- --------------- <br /> Well .____...____•----...__------------------Founclation <br /> Distance to nearest. -----------_----- Prop. Line .................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------- ------_------_ ............. Date ----------------------------- <br /> -Requirements) .............. <br /> Septic Tank (Specify .................. -----------••-------•----- ................ 0 <br /> -------------------------- <br /> ...,Disposal Field (Specify Requirements) ---------------•-..-•---••-•-•-•-----. ------- ------------------------------------ <br /> .............. ----------------------------------------------- ..................................................­­----------------------------------------------- <br /> --------------------- <br /> ----------------------------------------------------------------------------- -_----------------------------------------------_--------- --------------------------------------- <br /> --------------- <br /> (Draw existing and required addition on reverse side) <br /> A hereby certify that I have prepared this application and that the work will be,done in accordance with Son Jo <br /> aquin <br /> County Ordinances, State Laws, and Rules <br /> airid- Regulations of the San Joaquin Local Health District.Home owner or Ilcen- <br /> so agents signature certifies the following: <br /> �01 certify that in the performance ofF as to the work for which this permit Is issued, I shall not employ any person In such manner <br /> become subject to Workman't Compensation'law" s* of California." <br /> Signed ... ........... .............. <br /> . ..... . _7 -- --------------- -------------------- Owner <br /> qty, <br /> $y�......... ........ <br /> ----- ------ --------- <br /> ------- ----------------_--------- litle -------C_10f!f�--__ ------------- <br /> f other n owner) <br /> 42 FOR DEPARTMENT VSE ONLY <br /> APPLICATION ACCEPTED BY ---------•---------- ----------- ---­---------------- DATE <br /> 401WING PERMIT ISSUED ...... ......... ---------- <br /> DITI NAL COMMENTS ................................ ..............DATE ........... ............................... <br /> ---------------------------------------------------------- -------­---­-------- <br /> - - ----------------------------------------------------------------------------------- ------ ---------------------------------- <br /> .. <br /> ............ <br /> ----- 7---------*------------ I­ ------ ----------•-------------- <br /> -- <br /> ------------m------------------- <br /> • <br /> -- - - _.._...... ----- ------------- -- - --- --­----_--_.................................--------.---..- <br /> -.-.-.------------------------------- ...--.-.--.--.-.- <br /> --------- <br /> - <br /> --- <br /> Final Inspection by- ------------ ...Date------------------­-- --------------_ ............ <br /> ........... <br /> SAN JOAQUIN -LOCAL HEALTH DISTRICT <br />