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F <br /> FOR OFFICE USE: <br /> APPLICATION FOR-SANITATION PERMIT <br /> --------- --- --- -- - ------ - Permit No: <br /> (Complete in Triplicate) <br /> ----- <br /> ------ This Permit Expires I Year From Date Issued Date Issued __�'�`_rL... <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 /> ------- <br /> egulations: I <br /> JOB ADDRESS/LOCATION <br /> ------�_r__D- ---------G�______�s� _-_ -_- �- -CENSUS TRACT -------------------------- <br /> Owner's Name �!`/7G.t <br /> - Phone <br /> n0�- <br /> '- -----------------a l=Addressx a . (------------------ . Cit <br /> Contractor's l <br /> � <br /> Name .__.___.GP- .____._______.License #c '- _/_;1,�J_ Phone _ <br /> Installation will serve: Residence LyApartment House,❑ Commercial :❑Trailer Court :F <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:._/_._. Number of bedrooms <br /> ____/---Garbage Grinder `-sem__ Lot Size _-_.___- <br /> Water Supply. Public System and name ____ J' cf _____4:V ---------------------------------------------------------------Private ❑ f <br /> Character of soil to a depth of 3 feet: Sand'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam <br /> Hardpan ❑ Adobe k 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.) Nj <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { J SEPTIC TANK /_T' -/�4,Siie------------------------------------------------ Liquid Depth --_----------------------- <br /> CapacitY -------------------- Type -------------------- Material----------------- "': No. Compartments --------------..-_---- <br /> Distance to nearest: Well ________________________________Foundation ---------------------- Prop. Line ---------------_______ <br /> LEACHING LINEX No, of Lines / _ Length of each line___.___.Ve ..Q_f_.._.____ Total Length ---4<�Q................ <br /> 'D' Box ----0--- Type Filter Material _,r.r.A6______Depth Filter Materia! __________________________ <br /> Distance to nearest: WellFoundation ___�®__-________ Property Line ____--!�---___--____._.__. <br /> SEEPAGE PIT Depth ____ Diameter Number ------- --------_---------- Rock Filled Yes No C <br /> c r <br /> Water Table Depth ------- ---1- -- -----------------------•-- ----Rock Size ----------.2------------ <br /> Distance to nearest: Wel! ____________Foundation fQ' ------ Prop. Line _... _..____.___--__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ____________-_____________________} <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------=--•---------------------- ---- --------------------------­ <br /> Disposal <br /> -----------------------Disposal Field (Specify Requirements) ----- - - ---r--- -----�1��1 f.--------�`"'t =---- - --- --; -------------- <br /> ------------------------- -- - <br /> ^ pB /a �!�= n. <br /> 44 It <br /> hereby certify that I have prepared this existing <br /> an required d ad �_' ^ <br /> ------------------------------------------------------- <br /> dition on reverse side)�I 1 <br /> y y p p pp a work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heal th;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 ---------------------------- ------------------------- ------ Owner <br /> BY - Title ----- ----- ------ -------------------------- <br /> 15�(If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -- -- --- ------ - ------------------ --- DATE -—1 <br /> BUILDING PERMIT ISSUED ------------------------------DATE -------------•----------------------------- <br /> ----------------------------- ----------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> --------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------C>-------------------------- ----------------------------------------- <br /> --------------------------------- 4 <br /> ------ - ----- - - <br /> Final Inspection by:._-- ---------------- Date ^ "c _y'--o�-_.___------. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � . <br /> E. H. 9 1-'b8 Rev. 5M i <br />