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FOR OFFICE USE- <br /> r APPLICATION FOR SANITATION PERMIT <br /> �l �--•---/:�-�-•f-........._ Permit No. .-.7..�=��... <br /> (Complete In Triplicate) <br /> .......................................................... i Date--Iswed <br /> ._�.�.:_...... <br /> I This Permit Expires 1 Year from Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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/tOC—ATyION�..��1..,��.__.�Co.�... .��-�-- -L••• •- <br /> ....................................CENSUS TRACT .......................... <br /> Owner's Name .....// .LtI !/f� ......... ---•....................... :....:_...............Phone - <br /> Address . J f�....• ��� ...... 1.... ............ •........ ................................. .........._.. -•------- <br /> l� - . /� City <br /> Contractor's Name N sQ�... ..Gi/t/ -� *' ....-----.license# ... .... Phone <br /> --...... ... .... . ....... . <br /> Installation will serve. Residence[�iApartment HouselL] Commercial oTraller Court E] <br /> Motel Q Other <br /> Number of living units ------- Number of bedrooms ..--.._.__Garbage Grinder ............ Lot Size ... . .............. ....... <br /> Water Supply: Public System and name .7..... ....._.._...._.... --.........- ..:-................Private . <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay a Peat❑ Sandy Loam ❑ Cloy Loam <br /> Hardpan p Adobe gFIII Material ............If yes,type............:.. ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse aide.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if pyblic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ize...c ..4F .................•-------- Liquid Depth ... <br /> Capacity I1 ... _��,...._ <br /> 1:;: -�___._ Type P <br /> r Material_ No. Compartments -----Z ..... <br /> Distanceito nearest: Well f '� _� _..Foundation ./A.. -Pro 5-49 e- <br /> Line <br /> op• ._ <br /> LEACHING LINE [� No. of Lines ....... ................ Length of each line..... .__-•......"Total Length©©........ . <br /> D' Box t Type Filter Material g° Depth Filter Material �1 �, <br /> . <br /> .. <br /> i . . Property Line <br /> Distance to nearest: Well _�..0.___.... Fou ation .......... ......... 1• ••••••••••-•- <br /> SEEPAGE PIT Depth _.._P.J K_P`biometer d_-- Number _-_____----.�.. Roc Filled Yes, No <br /> Water Fable Depth ......0_9 `:------------------Rack Size <br /> os r <br /> Distance to nearest: Well ......�------------•-•...............:.Foundation .---..._.:..-•-•---. Prop. tine ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit+# ...--------.•----------------------•-------- Date -------------- ................... <br /> Septic Tank Specify Requirements <br /> I <br /> Disposal Field (Specify Requirements) ----•----••--------•-•----•--•-----••-•--• ................................ ........................................._......... <br /> --- --: <br /> -------------------------------------------- i ---......-•---------------.............--•------------•-- ................................................................. <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 Mules and Regulations of the San Joaquin Local Health,District. Hems owner or iicarn <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this ermit Is issued, I shall not employ any person in such manner <br /> as to beco a subsub ect ro rkman's�C en ti laws of Iifornia." <br /> Signed --------------------- -- ` ewner <br /> Jitie ..... .................---------- <br /> By ----- ----... -� ......._ ..._.. <br /> (if other than owner) <br /> F_ORR1DEPARTMENT USE ONLY <br /> F APPLICATION ACCEPTED BY � -------•-----------•--••-------------------•----. DATE <br /> BUILDINGPERMIT ISSUED --•--------------------------------------•-------------------- .....................................DATE .......... --••------••--....... .......... <br /> ADDITIONALCOMMENTS ------------------ -----------------------------------------...---------.-.-.----..----............................ ........-----......•••--.........-•...... <br /> --------------------------------•-------------------------------- •-------•--------------------- ---------------.....------•--•-------.....-................ <br /> ................. .. ......................... --------------:........ ..............-•------••-------...------------......----------......----.......--...........-----••---•-------.......-------- <br /> --........-•-- •----------------•--- --- --•- .... -------- ............... <br /> .--........Date -- ,�- <br /> Final Inspection by: •t�t�t�x -•. <br /> EH �3 2h 1-68 1L-v• 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />