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'FOR <br /> OFFICE°USE: APPLICATION FOR SANITATION PERMIT <br />.. - - ••--•.......................... Permit No. .............. <br /> /�. <br /> " (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date[slued <br /> Date issued <br /> _.._................................................. <br /> W I <br /> Application is hereby made to the San Joaquin LocaV 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/I OCAT N ... .. .. -_ .,..-- -- - .- ..................CENSUS TRACT <br /> Owner's Name ........ .. ................................... <br /> �.+.-!�. . ! -- - .. .. ,...:�._ �.-. .Phone . <br /> Address -- .Z �. ?.._.._.. �..__ ... 1�- City .......... :............................ <br /> Contractor's Name ►_.. .�+s ...... License # .1� Phone <br /> ..�`� <br /> installation will serve: Residence [�'�ipartment House Commercial ❑Trailer Court ❑ <br /> Motel ❑Other .........:....• -•----- <br /> ...... <br /> Number of living units:....J_.._ Number of bedrooms ---44 Grinder ............ Lot Size .... _I ....... <br /> Water Supply: Public System and name ----•-- •---------- --------------------------------------............................•........................Private <br /> Character of soil to a depth of 3 feet: : Sand❑ Silt❑ -Clay ❑ ' Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan Lfloo'Adobe-j] 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. s --- --'r `-------- Liquid Depth ...9-............ <br /> ------ <br /> Capacity 1�ko..:..__. Type ) .-C.t- _ Material----X-41"'"' . No. Compartments ............. <br /> ........ <br /> Distance 461 nearest Well ,5.�.:_J[ ............. Prop. Line .. <br /> ......Foundation ...Lfl__ ..�• <br /> LEACHING LINE [ No.. of Lines'.:....------_-. ' Length of each line.-__.__.4.f?..�.�' Total Length �.' .. �..._. <br /> 'D' Box _1........ Type Filter Material .......-r�---�'�....Depth Filter Material ------M../.... ....................... U <br /> Distance to nearest: Wel! ._..- _._._ .... Foundation ....f d_ .. Property Line ...` :_....__.__. <br /> SEEPAGE PIT [� Depth .......+4---I* meter -.::.. Number -------2................ Rock Filled Yes 0 No <br /> .Rock Size ___ ... - <br /> Water Table Depth ------------��-�•�•-�......--•--•---• � .�--........---•--- **�� <br /> Distance to nearest: Well -_._._-_-I_. ' .. �---__--Foundation __��. .._ Prop. Line .�.�t-_ ....... <br /> REPAIR/ADDITION(Prey. Sanitation Permit+# ............................................ Date ..................................I P <br /> SepticTank (Specify Requirements) ................... ...........•--......................._._...........:.._... •................................------------------ ...... <br /> DisposalField (Specify Requirements) ................................................................... •---•-•--------------------------------------------•----- -----� <br /> -----------------------------------------•-------...........------.--------- • --------------------------••----------------------...._.......-------------•----------------. ........................ <br /> .....--•........................... --------------- •--------------------•-- ---......------------------------•--•----•--........--•---•-----•-•------_..... <br /> (Draw existing and required addition on reverse side) <br /> € 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. Horne owner or licen- <br /> sed agents signature certifies the following: I <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 /> By ,.�� ... • Sitle .• ................................................... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... C_-, ....................................................... ................ ........ DATE ...../� - Z...��.•----_.... <br /> BUILDING PERMIT ISSUED _ DATE . .. ......... <br /> ADDITIONAL COMMENTS .. - -- -. •- ..... ..... ............••....•. .... ; <br /> ---------------I.........--- ................ f�... .....•.._..--•--------...---•----........ : ... .......... ............................... ..... ..... .............. <br /> ..........................................................................................•-------.....---.......-...................................... <br /> - 1 <br /> __ .. <br /> Finalinspection by: ...:.-•_.. zV................I.......----------- ...------...-•---...---...................................Date ... .. ..:/.f� .. ...--- <br /> SAN JOAQUIN -LOCAL' HEALTH DISTRICT LL <br /> r- w 13 24 I.-AA Re., JqAA M <br />