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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------- Permit No: 170 <br /> (Completein Triplicate) <br /> Date Issued <br /> _ . --.-_---...--_. <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 /> - ----CENSUS TRACT -------------------- <br /> �11 »• y <br /> JOBADDRESS/LOCAt.- - --------- =Owner's Name "°` -------Phone------------------•------------------Address ----- F� ---- ----- ---- - ------- ----- - -- -- - City ----- -------------------------------------------Contractor's Name -- ---- ---- --t -------License --- Phone ----------------------•------- <br /> installation will serve: Residenc [J�Apartment House❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑Other --------------------------------------------- <br /> Number <br /> ------------- ----------------------------Number of living units:______ .... Number of bedrooms ---4-----Garbage Grinder------- Lot Size -------------------- j <br /> Water Supply: Public System and name ----------------------------------------------•----------------------------------------------•----------------Private <br /> Character of soil to'a depth of 3 feet: Sand'❑ ,Silt❑ Clay. ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ <br /> Hardpan L—Iy Adobe '❑ Fill Material ------------ If yes, type--_--_--_------------------ <br /> (Piot 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,) O <br /> PACKAGE TREATMENT ( ] SEPTIC TANK I j 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 ❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest. Well ----------------------------------------Foundation ---------------.---- Prop. Line ---------------.•----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------..-._-----) <br /> SepticTank (Specify Requirements) -------- ---------------------------------------- ---------,-------------------------- -----:-------- --------.---------------------•------ <br /> Disposal Field (Specify Requir ents) -- # t s fi ; <br /> - j <br /> 4 <br /> - ------------------------------------- -- <br /> (Draw existing and required addition on reverse side) <br /> j I hereby certify that I have prepared this application and that the work will be-done in accordance,with.Son 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 - --- -- - Owner <br /> i --------- ---------------------- 'a- <br /> --- --- ----- <br /> Title ---- - --- ----s ----------- -------------------- <br /> By - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ------------------------ --- ---------------------------------------- <br /> 7 <br /> DATE �a� 2. <br /> BUILDINGPERMIT ISSUED ------- ------ -------------------------------------------------------------------------- ----- --------DATE -------------------------------•----------- <br /> ADDITIONALCOMMENTS -- ------------------------------------------------------------------------------------------------------------------------------ ------•--•------ ---------- <br /> -- ---------------------------------------------------------------------------------------------------------------------------------------- ------------------------- <br /> ------------------------------------------ ------------------------------------------------- ------------------------------------------------------ -- ------ -- . <br /> ------------------------------------ --- <br /> -- <br /> Final Inspection by: ---- ------------------------------------------------------------------ Dati -'_ -_ -7� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 <br /> E. H. 9 1-'b8 Rev. 5M, <br />