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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />�j�u�r' -------------------- ------------------- -�- Z <br /> ..N. scat Permit No. Z: . 3•---- <br /> " <br /> _______(Complete in-Tripl' el <br /> This Permit Expires T Year From Date Issued <br /> Date Issued <br /> _ <br />- --------- - _ _ _ <br /> ----- --- -------------- - ------- <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 . o �'� --------- <br /> Owner's <br /> f ------CENSUS TRACT --------------•---- ------ <br /> - ------ -Phone _ <br /> Owner's Name ------------ SIL- ---- ; -Cit - � <br /> - ------- ------------------•--- <br /> Address -------------- <br /> --- ---- - = CK✓ ----- ------- Y . --------•-- <br /> .:-7D__4_ <br /> # . a � - -- F6 <br /> Contractor's Name �.L.J-- ----- ----- '----------------- ------------------------�-- ---- License Phone <br /> Installation will serve: Residence Apartment House ❑Commercial ' Trailer Court ❑ <br /> -----'---------------'------------------ - <br /> Motel❑ Other� - - �• <br /> of living units:.= ____._ Number of bedrooms ____,___Garbage Grinder _..' ~.- Lot Size .____ --f- ----------------------- <br /> Number t <br /> _- -:-I rr <br /> Water Supply: Public System and`name - -------------------------------••---------' --------------------- Private <br /> Character of soil to a depth of 3 feet: Scind'❑ Silt❑ Clay ❑~ Peat ❑ Sandy Loam .❑ Clay Loam ❑ <br /> t Hardpan_❑ Fill Material _____:_----- If yes, type ___-------------------- <br /> (Phot _plan, showing size of lot, location of system In relation to wells buiEd.in_gs, etc.must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank orseepage pit permitted if-public sewer is available within 200 feet,) <br /> ] f Size Liquid-,Depth _.__- ------- -- l <br /> PACKAGE..TREATMENT t ] SEPTIC TA <br /> capacity <br /> -* Type = '` t *Material Na. Compartments. •--•--. <br /> C ' l <br /> i - Distance to nearest: Well --- -- ---------.Foundation ---------------------- Prop. Line -----------••:•-_-__-- <br /> LEACHING LINE [jLt No. of Lines -- ---------- Length of each line------- Q--__---- Total Lengtht --'y_____ <br /> 'D' Box --------,-Type-Filter--Material ..___�__- ___Depth Filter Material --_--- <br /> ------ <br /> Q Pro er Line. <br /> Distance to nearesti-Well-� -- - Foundation _____�_----------_ p ty <br /> SEEPAGE ___ Number _____--' - ------ Rock ❑ No C PIT L l Depth -------- ------ Diarriet�r.--_----------- Rk Filled Yt <br /> Water Table Depth - ' = ------Rock Size -------------------------------- <br /> Distance to nearest: Well - _.._ -::--#=-----------------------Foundation --------------------- Prop. Line ---------------------- -- <br /> W, <br /> REPAIR/ADDITION(Prev._Sanitation_P_er..mit#_..___..._..._F-----------------------__-- Date _______.---____________----------1` <br /> a � i <br /> v <br /> Septic Tank {Specify Requirements) ------------------------------------�.----�----------------------------------------------------•• -- --------------------- <br /> I �` --- ----- -------- -- <br /> Disposal Field (Specify Requirements) ---------------- - -------- i-- i <br /> ti <br /> -<-, > <br /> i ---------- --------------- <br /> (Draw existing existing and required addition on reverse side) <br /> II hereby certify that I have.prepared this application and that the work will be done in accordance with San Joaquirt <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.' a <br /> Signed - - - ::-Owner <br /> C7 <br /> Title . <br /> ---- <br /> 8Y � ----- - ---------------- -- - ----------- <br /> (If other than owner) <br /> R ,2. R ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------''f--;---- -- -- - -------------------------------------------------- DATE <br /> ----- <br /> BUILDING_.PERMIT.-ISSUED...-- '= -------- - ---- -------DATE <br /> -._ == <br /> ADDITIONAL COMMENTS ------f%<---- ----- ------ ! --- --- -- ' <br /> =----------------------- ------------------------------- -------------- <br /> �/ ,L ' , ', ----- ---------------------- <br /> _____________________________________________ ___ ______ _ _ -------_----------------_-------------------------------------------------- <br /> _._______-_________________ _ ___ _ _______ _ _ ------------ ----------------------------------------------------------------------------------------- <br /> I <br /> FinalInspection by: ------ - --- ------------------------------------------------------------------------------•Date = - ---- <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1268 Rev. 5M ".r <br />