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FOR OFFICE USE: <br /> .30 APPLICATION FOR SANITATION PERMIT <br /> -- �° -- ----------- V` ----- g X11� �5 <br /> "� Permit No. .._____ <br /> (Complete in Triplicate) -------------` <br /> -- ------------------------ -------------- <br /> -------------------------------------------------- This Permit Expires 1 Year From Date Issued bate Issued <br /> Application is hereby made to the San Joaquin Local Health District for a -permit to construct and install the work herein F <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: r <br /> t <br /> JOB ADDRESS/LOCATION . -- �------- ------------------ ------------------------CENSUS TRACE' --------_-------------- <br /> Owner's Name p ------ <br /> ---- --------------------------------� ------'------------------------------------------------ <br /> --------- -----------------------------------Phone ------------------------------------ <br /> V. <br /> Address ----------------- i9/ .e.---------- --------(•--------------------------------?---------------- City .-_ ----------------------------------------------- <br /> 9k. t <br /> Contractor's Name - ``—--------------------------------------------License # (v -Z _ Phone <br /> Installation will serve: Residence P_<Partment House�❑ Commercial ❑Trailer Court 'C7 <br /> jj Motel F1 Other ---------------------------- <br /> Number of living units:__--__l__. Number of bedrooms ----2----Garbage Grinder ifi�--- Lot Sizezf-_______________ <br /> Water Supply: Public System and name ----------C4tAlF-------�`� -------- --------------------- ---------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam (]; Clay Loam r7 <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: f No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ; <br /> J, f � p <br /> PACKAGE TREATMENT [ } SEPTIC TANK [�f Size-------- <br /> [--- ----- - Liquid Depth __#_1X--------------- W <br /> Capacity _J1 U____,__ Type _ �� Material(. t_r_0_:fr. No. Compartments __________________ <br /> Distance to nearest: Well .--_-�----------------------Foundation --_ Prop. Line S------__- <br /> LEACHING LINE [� No. of Lines --- --------'_-_____- Length of each line-----/_v_4_.1----------- Total Length -------------- <br /> � <br /> 'D' Box _1VP____ Type f=ilter Material _:� rY10 ept <br /> q_ h Filter Material At t___._ <br /> ----------------------------- <br /> Distance to nearest: Well ---_ _------------ Foundation --------------- Property Line _S'--___-_-_-----__ <br /> SEEPAGE PIT [k'] Depth _ _ -{-------.- Diameter 2�4_-'`------ Number -------- ------------------- Rock Filled Yes [�2 No C <br /> Water Table Depth ----------- I ` <br /> --------------------------------Rock Size -- -��-" ------- -,------- <br /> Distance to nearest: Well -_Y'r�_____________ _____Foundation _--gip.` ____--- Prop. Line ................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------_-__' ------------- <br /> r Septic Tank (Specify Requirements) ------ -------------------------------------------- ------------ "- I--------------------------------------.--------------------------- <br /> 4 { <br /> Disposa Field (Specify Requirements) =-------------------------------------- ---------- ---------------------------- ----------------------------------- <br /> ----------­ <br /> --------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- -- -------------------------=------- ---------------- <br /> ------ ---I----------------------- <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------------- --------------ii---,-� - ----------------------------------------- Owner <br /> By ------------ -- ---- -- --- -- 1�C�_�-- - ---------------- Title ...0-�. ti <br /> (if e� than owner) <br /> - -- ------------------------------- ------------ <br /> R . ARTMENT USE.ONLY <br /> 9 <br /> APPLICATION ACCEPTED BY ------- ----- - - <br /> ----------------------------------------------------- DATE ` - ----------------- <br /> BUILDING PERMIT ISSUED -------- -- - --- ----- --- ----------- ----------------- --------------- ------------DATE ---------------------- <br /> ADDITIONALCOMMENTS ----- -- - ---- ----- ----- --------- - ------------------------------ --------'------------------------ -------------------------------------- <br /> ---------------------------------- <br /> - �- - -- :-- -.- - ' <br /> P ----------------------_________________________ ___________ _ -__- --- . . _-_ _ - ----_--------------- <br /> ___ <br /> Final Inspection b : - ------ - --- -- --- -- -----------------------------Date .= -------- ---- <br /> N QUIN "LOCAL HEALTH DISTRICT - <br /> u � � <br /> E. H. 9 1-'b8 e . SM s <br />