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FOR OFFICE USE:o APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. ............ ....• <br /> ... .: <br /> . ....................................................... This Permit Expires t Year From Date Issued Date Issued ..�:5'_-7S <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 Co u ty Ordinance o. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO ... �..... ..:.. ....CENSUS TRACT <br /> .. a ... _. <br /> r <br /> Owner's Nome . ......Phone�6.`te:n.®-°-� -- <br /> Address G __. -- City •...--- <br /> Contractor's Name yr. .License # .. Phone .-.��..-.f'.Os 7._ <br /> R <br /> Installation will serve: Residence,KA.partment House f] Commercial OTrailer Court <br /> Motel❑Other.... <br /> Number of living units .. Number of bedrooms-3,forbage Grinder Size ',?�_.1.ZS <br /> Water Supply: Public System and name ............................. •-- -. --- - ._...�„L_d4.��.t3_....... _.....+.....................Private Q. <br /> Character of soil to a depth of 3 feet: Sand[3 Silt 0 Clay 0 Peat.Q Sandy Loom 0 Clay Loam.Q� . <br /> Hardpan p Adobe ef, 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,! a <br /> PACKAGE TREATMENT f ] 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 ............................ <br /> 'D,' Box ------------ Type Filter Material Depth Filter Material { <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ................... <br /> r <br /> SEEPAGE PIT Depth Diameter ..........:..... Number ____- ____._-_-_---_-__---.- Rock Filled Yes ❑- No ' <br /> Water Table Depth ................................................Rock Size ............ .......... ........ <br /> Distance to nearest: Well _.....foundation -------------------- Prop. Line ...................... <br /> RIE:PAIR/ADDITION(Prev. Sanitation Permit# ... ........................ Date ................ } <br /> SepticTank (Specify Requirements) ....... .......................m.............................................z---------..................... <br /> Disposal Field (Specify Requirements) ............ ----- ........ "2t r <br /> ....../_n...ID..... -,O.�--------------- .. <br /> .. <br /> I -•.............................. -- --------------- - --- .......... ...........-•............................ <br /> (Draw existing and required addition on reverse side} � ' <br /> 1 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 Joaquln local Health;Dlstrict. Horne owner Or Acen- <br /> sed agents signature certifies the following.- <br /> "I <br /> ollowing:"1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person in such manner <br /> becomeas to - an's Compe ws of California." <br /> r Signed�sub ect Q mQ15::64�-_�se�tesnla`_ ---•--*-gmer <br /> > BY �.. . . <br /> - .. <br /> (if other than owner) <br /> ' FOR PEPARTMENT IL13f ONLY <br /> APPLICATION ACCEPTED,BY ------ .... DATE <br /> BUILDING PERMIT ISSUED --------------•---.--._---- DATE .---...._._...__..... <br /> - ....__-...............•---•--• ---.--•-----....--- ----•----------- .__. <br /> ADDITIONALCOMMENTS ------------------------------•-••---- ..........................--------.................-.....----•.-•---------------- ------------------..__.........------- <br /> ------------------------------------------------------- ------------------- ----- ---------------------------------------------------------------------------------------- <br /> - <br /> ------•------------------------------- ---- - .----- ---------------------------------------- -- <br /> a <br /> Final Inspection by: .... • ..__.._.. ......................Date .. `- <br /> EH 13 24 1-613 1fiat►. SAN JOAQUIN :LOCAL HEALTH DISTRICT 8/74 3M <br />