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F FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ,. <br /> rJ`�1 -- <br /> Permit No: __ '- �- -- <br /> - - - (Complete in Triplicate) In "- 1� <br /> ---------=--1-------------------------------------------- Y <br /> .� Date Issued <br /> ______ •--------------------- This Permit Expires 1 Year From Date Issued <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-- �`' --- ---- ----- ' �' Gl/- l--S CEN$US TRACT --------------••---------- <br /> Owner's Name Phone <br /> '� / l`"�/ `� City ---- -------�------- ---------------------------------•------•-- <br /> Address IAVA-------- ------ ----- J <br /> 50? 5 --- - Phone ems'�-'---- <br /> s <br /> > Contractor's Name :-� ---- �`� - � -�--'�--�--------------License #�-- --�-- - - ���---��- -- -••- <br /> Installation will serve: Residence VApartment House❑ Commercial ❑Trailer Court [ <br /> Motel ❑ Other -------------------------------------------- <br /> M <br /> Number of living units:---I------ Number of bedrooms -,3-------Garbage Grinder Lot Size ----- ---------------------.- <br /> Water Supply. Public System and name ------------------------ --------------------------------------•--------•------------Private P <br /> Character of soil to a depth of 3 feet: Sand,1] Silt❑ Clay ❑ Peat❑ Sandy Loam P__�Icly 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 /> t NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I ] SEPTICTANK;W Size---41_X-17_X------ ------------ Liquid Depth _-_- -------- C <br /> Capacity /�_qO------- Type -------------------- Material Compartments ----4...-•---=---- <br /> Distance to nearest- Well .___-5---- -----------------------Foundation -_-- ------------.Prop. Line --___-',> ___-.-_-- <br /> LEACHING LINE [y---No. of Lines ----�--------------- Length of each line------!FQ---------------- Total Length ,--/_- �•-------------- <br /> 'D' Box ---1-------- Type Filter Material _ -----Depth Filter Material ------ <br /> to nearest: Well ---ST-------------- Foundation _-.1 --------------- Property Line. ----- ____._._--- <br /> SEEPAGE PIT Depth ----- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> - <br /> Water Table Depth =------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------- ---- Prop. Line ------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- ------------------- ---- Date -------_---------_--------------) <br /> Septic Tank (Specify Requirements) ---Kr„-'-1------------ --- ---------- ----------------------------- ---------------­-------------e---------—----------------- 3 <br /> t <br /> Disposal Field (Specify Requirements) ------------ ------------------------------------------------------------------------------------------------ <br /> --------------------- ----------------------------------------�--------------------------------------------------------------------------------------------- <br /> ------------------------- --------- ----------- <br /> 4 (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. 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 Workmman's ompensation laws of California." <br /> Signed tA-� g Ate. � Owner <br /> ------------------- -------------- <br /> By _.- ---------------------- Title --------------------------------------------- <br /> - --- --------- -------- -- -- ----- ---- ---- -------- <br /> (lf other thalf owner) <br /> FOR DEPARTMENT USE ONLY <br /> YDATE - fir ---- ------------------ <br /> APPLICATION ACCEPTED BY - -- --------------------------------------------------- <br /> BUILDING PERMIT ISSUED ----------------------------------- ----------------- <br /> - ----------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------- ------ ---------------------------------------------------------------------- ---------------- <br /> -------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- <br /> - ------------- <br /> -------------------------------- - -- --- -------------------------------------- ------------------------------------------------------a <br /> -- ---- - - <br /> Final Inspection by Date --o' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1268 Rev. 5M, <br />