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fOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................... ..............................r-�--- Permit No. <br /> (Complete ff (Complete in triplicate) <br /> �................ ............................. <br /> This Permit Expires 1 Year From Date Issued <br /> . Date Issued . .... . ] y <br /> ..� <br /> ! -------------- -----••--......_..--- .... ----_,.... <br /> h <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to constructand install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> as bel C -Q .- <br /> JOB ADDRESS/LOCATION. ._.... ...- .........CENSUS TRACT ........_........... <br /> :.... <br /> Owner's Name .-------------- -------------------------- --------•-•-...............Phone ................................ <br /> I ' <br /> Address ....._................ City <br /> Contractor's Name .- ---; ................ ..... License # ........._.....----.... Phone ................ <br /> Installation will serve: I Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel XOther <br /> Number of living units-...' <br /> �h _._,. Number of bedrooms __-k........Garbage Grinder ............ tot Size __.........................................\ <br /> Water Supply: Public System and name ................................---------- ---------------------------------------------------------------Privatex \ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ 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.N <br /> NEW INSTALLATION: (N� septic tank or seepage pit permitted if public sewer is available within 200 feet,l <br /> PACKAGE TREATMENT [ I SEPTIC TANK Size-__........................ .. ........ Liquid Depth .......................... <br /> � <br /> tit --11 <br /> C kpacity .� � Type -. Materiai...0 No. Compartments .9^..-`------•--.- <br /> Distance to nearest: Well . _115.._..........-._..,'....,Foundation ..,�_a.............. Prop. Line_-aO ............ <br /> LEACHING LINE ] No. of Lines t . length of each line. ....O0.o.............. Total Length ------ -------- <br /> 'D' Box .._._ . . . Type Filter Material __.._ Depth Filter Material _.._.�g.....___ <br /> 11 <br /> Distance to nearest: Well ----'-•1....-----------.. Foundation _.f_............I... Property Line <br /> SEEPAGE,PIT f ) Depth . ... _._....._.... Diameter -__.___.- Number ..___. .......:_ Rock Filled Yes ❑ No t; <br /> t Water Table Depth ------ ..............: Rock Size ..... -------­---------------- <br /> Distance to nearest: Well ---------------------------------- ----Foundation .............. Prop.,Line ------ .............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...._....---•-............................. Date ------.....................•------ <br /> ) <br /> Septic Tank (Spec.ify Requirements) .... ................--.--...- ..........--...-............ <br /> -Disposal Field (Specify Requirements) --------------------------------- ..........:..... ........•..._._-. ---.......-•---•--- <br /> �_... ---- ----------------------- ..----------..... ............ <br /> ............................. <br /> -. 1......_...- <br /> ....... ......... ..... - . -- -•--.... --......------- <br /> (Dra'w 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 licew <br /> i sed agents signature certifies the following:_..__ 1 <br /> "I certify that'in the performance of the work for which this permit is issued, 1 shalt not employ any person in such manner <br /> as to become sub' -t t i orkman's Compensation laws' of California." <br /> Signed .: ..-/.i �! ------ Owner <br /> ..._.. ....................... . <br /> By -. •�i � � . _,,. ..+ _ itle . .. ... .._.. .............. <br /> t (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... ... . ...... -------- ...........................-...--- ----- ......... _.__. DATE ... ]. .c-a. _. -..4.............. <br /> BUILDING PERMIT ISSUED -- ......DATE . ......................... ............. <br /> ADDITIONALCOMMENTS 'i-_- ------------- ---------- -----------------------------•----------..------------------------------ -------- --------------------- ------ <br /> ..... --•--------- ----------------- -- ----- ,y <br /> Final Inspection by: ........ -.. ........................................ ----.......Date ...... `: ......... <br /> I <br /> i <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a � i y <br /> E. H. 13 24 t-'68-Rev. 5M'i _ - _._ ._7/.32.3 .K <br />