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FOR OFFICE USE: <br /> OLICATION FOR SANITATION PER ((// <br /> (Complete in Triplicate) <br /> Permit No. .....7`......... <br /> This Permit Expires 1 Year From Date Issued Date Issued ._...__..._.�....7 <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/LOCATIO �.�. <br /> , 3�- ---..,.�.. ...........� f � . ..........................CENSUS TRACT .......................... <br /> 1 <br /> Owner's Name ....... �',h--�t_.C."., .c.._... `.......................•-------.,..............._.. ...............Phone .................................... <br /> lf . . c/ <br /> Address ..... �� ' � r _ ' <br /> ----•----r��..,�._..��:=--------------•----�---.�.------.. �........----------....... City - - �..-...........----•--.................................... <br /> Contractor's Name Ga . ., -�..... �. .._..�<,_/r ....License # ..1.7f.3��hone <br /> Installation will serve: Residence [ partment House 0 Commercial Trailer Court <br /> Motel ❑Other ............... ------•----•--------•---•--- <br /> Number of living units:...-./.... Number of bedrooms ......t Garbage Grinder ............ Lot Size <br /> Water Supply: Public System and name ---------•----------------•------•-----------------------------------------•----•----•-....---•-----•------••.Private <br /> Character of soil to a depth of 3 feet: Sand❑ ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan Adobe ❑ 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................................................ Liquid Depth .......................... <br /> Capacity .................... Type .................... Material...................... No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of each line..................._........ Total Length ....._.................... . <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ \ <br /> SEEPAGE PIT [ ) Depth .................... Diameter ............... Number ............................ Rock Filled Yes ❑ No ❑ p - <br /> Water Table Depth ................................................Rock Size ................................ TIJ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................I <br /> Septic Tank (Specify Requirements) ................ .................. <br /> . .... . ... <br /> --.................................. <br /> ............................................................. <br /> Disposal Field (Specify Requirements[, ..._Q- _ 1....,.??'`......�Q'��d �.._� ._....� _. :.f.:� J: _. �,a..._.__ _.. <br /> / 4 <br /> (1�-tP <br /> •----.-:�K_c:�✓.....=fir= ='•.t. •. <br /> ...... ...... ..............................._.._..........-----•-•--------------•-•-•-•--••------•----.•.._-----•----.......--•--............_.........----•--------•----............._..........------ <br /> (Draw existing and required addition on reverse side) <br /> 1 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. 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." <br /> Signed ........................... ---------- =... ^......... Owner <br /> BY �� !:�-.:__L�_� Title ..... ......�t:...::.w:' <br /> ...................... _................ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... == :t s:f!f..................... DATE ..-`�.' ....�.----•-------------. <br /> BUILDINGPERMIT ISSUED ..................................-............................................-..........................DATE ..................._....................... <br /> ADDITIONALCOMMENTS ..................•-----.............................---•----•--.._............--• -•---...................................................................... <br /> --•---....--•--------------------------------•---•----•--.....-------------------•-------•-----•-----•-•-----------------•-----------•-----------•-------------•---•._.......--------•---•--.._.......__. <br /> ------------------------------------•-••-......---....� ...-----..:........-••---•----•••------------...-------••--------•---------------....----•-......----- .......................................... <br /> Final Inspection by: �.::.. :;t. .� <br /> ..............Date .)..".........._'7`' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c u 13 24 , .,Lo n_.. e,%A ��� u <br />