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FOR OFFICE USE: { <br /> APPLICATION FOR SANITATION PERMIT <br /> .------ -----..... ......................... (Complete in Triplicate) Permit <br /> ............................ .. <br /> - -- <br /> This Permit Expires 1 Year From Date Issued Date Issued .9r.� ��-.. <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 existingRules ules and ulpr- <br /> JOB ADDRESS/LOCAL�._ ~_-..� ........; . CENSUS TRACT .....��... ._.. <br /> Q <br /> Owner's Nam ------ --------•---------- Phone . <br /> Address <br /> s.�. �' . . .... -_..... ...... . City - 1 ............. <br /> Contractor's Name .......... :.. ...... � !`1. License # /.�s�. .. Phone .. ..-.... .... ............ <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court '❑ <br /> }} Motel ❑Other ............................................ <br /> Number of living units:.......1. Number of bedrooms .._3_.-.Garbage Grinder ............ Lot Size ............................ .-_..._.. <br /> Water Supply: Public System and name ..................._ .------•-------- -------•--- ---- ---•-------------•------------------------------.Private [� <br /> Character of soil to a depth of 3 feet: Sand 0 ,Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan [!I Adobe ❑ Fill Material ............ If yes,type.............. .---_-_-:- <br /> IPlot 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 i.n" Size. .1 ..��... .-.!r�... Liquid Depth ...L.................. <br /> Capacity ©Q.�'J Type Material. No. Compartments � . _ <br /> Distance to nearest: Well ........ >d.- .........Foundation Ja--_---._-._.-__. Prop. Line .......... ...... s <br /> LEACHING LINE [ No. of Lines 3�._ length of each line......`-EP............... Total Length ................ Op <br /> 'D' Box ._:.L...... Type Filter Material __-S_ .....Depth Filter Material ----- <br /> � ! <br /> Distance to nearest: Well _ - .50 ... ...... Foundation _-L.Q...._........ Property Line ........................� <br /> SEEPAGE PIT [ Depth ... Diameter ----3_.2;-.. Numbe _- . .,j................ Rock Filled Yes j' No [] <br /> Water Table Depth .-------------ci--- ---------.... �.1 X ... ------ 9 <br /> '� � .Rock Size _ �_ ._ -- � > <br /> Distance to nearest: Well Q .........Foundation d ---- <br /> Prop. Line ­-------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# __.. -------------- ..... Date . ................................I <br /> Septic Tank (Specify Requirements) ----. r <br /> Disposal Field (Specify Requirements} <br /> -------------------------------------- <br /> - -------------------------- -- ---- . • -- .-._................................---...... ----................... --.--------------------------..........- ............. <br /> ---- ---------------- ------ ---- -----------------•----••-----•----- ------•-----•. ----- ---- ......... . ---- . ---------------........................ <br /> (Draw existing 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. }come 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 ................•---........ Owner <br /> By .. .............................................. '1" ,� <br /> - 'tie .... .. ....... .......................................... <br /> (If other than owner) <br /> R DEPARTMENT USE ONLY <br /> EOp 1 <br /> APPLICATION ACCEPTED BY _ DATE . I.0'`/7... <br /> BUILDINGPERMIT ISSUED .............•-•••......... ----------- ..............................................................DATE ........................................... <br /> ADDITIONALCOMMENTS ....................................................... .. ....._...... ...... ................ -- ........._:........................... <br /> -- --------------------•-••..........----...................---•-------------..... ............................................................................................................ <br /> . .................. ------•---------- --------- ................._...._................................................ <br /> ...................... <br /> ............................................. <br /> Final Inspection by: - .. Date ��_.++pp- <br /> .1.. ------......... ... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />