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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> Permit No. -----7a-_ <br /> --------------------------------------------------------- <br /> (Complete in 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 /> JOB <br /> I I � Regulations: <br /> JOB ADDRESS/LOCATION ----- -CENSUS TRACT - -` ----------- <br /> ----- <br /> � <br /> -------------- <br /> Owner's Name -------- -- - --- - -------- <br /> ---------------------------------------- - ---------------Phone <br /> Address ------------- - -- <br /> City --- ------------ ---------------_-- <br /> Contractor's Name ----- __- -` '-----.License # -� - Phone ---------------------_------- <br /> Installation will serve: Residence [Apartment House[] Comm ial ❑Trailer Court ',❑ <br /> Motel ❑ Other - --_ - ----- -----A VI-P-� <br /> Number of living units:- 1------. Number of bedrooms ---_Garbage Grinder --------- -- Lot Size -----------------------------_------_--___-. <br /> Water Supply: Public System and name -------------------- -----------.-------------------------------------•-----Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt El Clay ❑ Peat❑ Sandy Loam � Clay Loam ❑ <br /> Hardpan ❑ Adobe-❑ Fill Materiat ------------ 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 permitted1 if public sewer is available within 200 feet,) <br /> k PACKAGE TREATMENT [ ] SEPTIC TANK �SizeY-_la__t _ ---./ �---------- Liquid Depth ._ ---------------- (n <br /> " Hyl <br /> Capacity ` _.__ Typ Material--- -- No. Compartments ________ -------=---• <br /> _ <br /> Distance to nearest: Well --------- 1------------------Foundation -----,t!10_1------- Prop. Line -----5-----•------- <br /> � '�J ,�• <br /> L [ ] No. of Lines _--'�--------------- Length of each line --- Total Length --•---------------_--- <br /> __ � <br /> 'Q' Box ------------ Type Filter Material ------.5 K--__Depth Filter Material ---------/if---_------.. ------------- <br /> Distance to nearest: Well ---_-----AV= -_.-_ <br /> -_----- Foundation ... ` ------- Property.---_ p <br /> � Line' _-07_11 <br /> -- ---------•----• . <br /> [ ] Depth -------------------- DiameterNumber -------------/--------- --- Rock Filled Yes No i <br /> Water Table Depth -----------------r --------------------Rock Size l --------- <br /> .-_Foundation 10 ' Pro Line --�---------------- `tet <br />� Distance to nearest: Well -------. P_______________________ ----- -------•---- P• <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------ - Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------- -----------------------------•--------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------- ---------- ----------------- - -------------------------------------------- -------------------------------------------------------------•------------ <br /> (Draw existing and required addition on reverse side) ` <br /> I hereby certify that I have prepared this application and th-at 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 mannef <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------------ ' Owner <br /> BY �� - Title .Q" <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY " -------- ------------------------------------------ DATE ----------------- <br /> BUILDING PERMIT ISSUED ----------------------- ---------------------------- - <br /> ------------------ ---------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------- -- ----------------------------------------------------------- ------------------------------------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - <br /> -------------------------------------- <br /> ll <br /> ----------------------------------------------------------------- - -- ------ --------------=------- <br /> Zai - f ` '- --------------- DateFinal inspection by <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT,, <br /> E. H. 9 1-'68 Rev. 5M �U <br />