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FOR OFFICE USE: I <br /> APPLICATION FOR SANiT'A'9`10N PERMIT <br /> (Complete in Triplicate) <br /> Permit No. .......-. <br /> _.. . .. . _.. This Permit Expires 1 Year From Date Issued <br /> 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/LOCATION .... c mfr .. _ .....CENSUS TRACT ... . . .... ... . .._ <br /> Owners Name .......... .............Phone .................. •................ <br /> Address ` -- .w!...... ...'�'`� ...:...... :; . .....'��......... City =f. - <br /> .. [•.. r� <br /> Contractor's Name ........ # � i.�' ..l":. Phone .. <br /> Installation will serve: Residence ❑ Apartment House-E] Commercial ❑Trailer Court :❑ <br /> Motel ❑ Other ----- --------------- <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder _... ....... Lot Size ............................................ <br /> Water Supply: Public System and name ---------• -•--------- ---------_------------------------ • ------------- -•----------Private <br /> Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ___4... 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:F J Size------------------------------------------------ Liquid Depth .......................... �f) <br /> 0 <br /> Capacity ......... ........ Type .................... Materia!------------ -------- No. Compartments ---................... <br /> Distance to nearest: Well ....................................Foundation ---------------------- Prop. Line ...................... rs1 <br /> t' <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 /> SEEPAGE PIT [ ) Depth ..... .............. Diameter -------- ------- Number .........------------------- Rock Filled Yes ❑ No i❑ 0 <br /> Water Table Depth ................................................Rock Size ................................ 6- <br /> Distance <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date .................................. <br /> Septic Tank (Specify Requirements) ......... - - ---------- <br /> --------------- <br /> •------•- l <br /> Disposal Field (Specify Requirements) =��_c.. t:__ :2 sig __ ^�_.__t _� ........... .,:. <br /> P(Draw <br /> %______ _______ _ .. ... __ ..Jh:.Sn:.. � :� -:fG-- -'.....-_. .� .4P .__._...': L�... /exAtingi�and required addition on reverse side) <br /> I hereby certify that I 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 /> sed 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 ................................. t'.... ._.. .. ... Owner <br /> t <br /> By . _ _ .........__.................,.. :f�, -t <f.. = 1 r` r Title ....: �?�:�r ! f�f. .L .. .................. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. ----------------------------------------------. ----------------------------- DATE <br /> BUILDINGPERMIT ISSUED -----••---•-•----------------------------------•--.-.-.......-.---._... .....-•--------••---------•-----._DATE ... ....................................... <br /> ADDITIONALCOMMENTS -----------------------------------------------------------------------•---•-----••--------•--.....--------....---•--------.......:..........-••..........-•-- <br /> ................................ ----- ---------------------••-•--•---...••--••-••--••-------•---•--•---•----------......••--••-•--•-••--•••-----•---••------•••••••---••••----•--•••-•--••............--- <br /> ..----------•----------•--• ......................................... -----••----•----......-•----....---•---•-------------------------------- .......... <br /> ---------- --- <br /> Final Inspection b .....Date .... ' <br /> P Y: ................. --••---•--.._....._.._.. ....,X. Z!.................. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F u 13 24 ,-,AQ Do„ rAA 71-7 u <br />