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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------- ------- ------------------------- <br /> {Complete in Triplicate) Permit No. <br /> = rl�___________--------------- This.Permit Expires 1 Year From Date issue sued <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/LO ON - -LS----.---- - --- ----- ---- - - ----- ----------------------CENSUS TRACT -------------------------- <br /> Owner s <br /> ------------------------- <br /> Owner's Name - ----- ---- --`---- ------ -- ----- - - -------------------------- -------- -Phone -------------------------------•---- <br /> Address / �t - -------- --- ---------- --- Cityi �s----------------------- <br /> x 1 / <br /> Contractor's Name ----- - --- --- - ----- - -.License # / 3 r Phone ------------------------------ <br /> Installation will serve: Residen a Apartment House-0 Commercial ❑Trailer Court ;❑ <br /> I t Motel F]Other-------------------------------------------- <br /> Number of living units:--- L_--__ Number of bedrooms .-3-----Garbage Grinder ____ Lot Size __fir��i'`� _____________ <br /> w <br /> Water Supply: Public System and name ----------------------•--------------------------------------------------------------- ------------Private <br /> Character of soil to a depth of 3 feet: Sand'El Silt 0 Clay E] Peat❑ Sandy Loam • 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.) <br /> NEW INSTALLATION: (No septic flank or seepage pit permitted if public !ewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ Liquid Depth ... ............._ `(� <br /> -k-0-o- Type }---- Material- _ ---- _ o. Compartments -��-----.- \ <br /> Capacity <br /> Distance to Weare Well ;-----------------------------Foundation ---J_tl_............. Prop. Line _---____ <br /> i .� _V i <br /> LEACHING LINE [ No. of Lines _____. Length of each line________YQ______________ Total Length __0� 0--- ---------- <br /> r . D' Box _-- Type Filter Material ---\�_+�------Depth Filter Material --- - ------------------- --------------- <br /> Distance: nearest: Well _______Sb_-_________ Foundation�!_�1________________ Property Line _--_-.___.__--_ t <br /> SEEPAGE PIT [ ] Depth _!_________________ Diameter ________________ Number ---------------------------- Rock Filled Yes [] No .l] <br /> Water Table Depth ---------------------------------------=---== Rock Size <br /> r <br /> Distance.to nearest: Well -----------'----------------------------Foundation -------------------- Prop. Line --------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________} <br /> rSeptic Tank {Specify Requirements) -------------------------------------------------------------------------------------------------------------,----------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> I ------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------• ---------•-_--------- <br /> ------------------------------------------------------------------------------- --- <br /> (Draw existing and required addition on reverse side} <br /> I hereby certify that I harie 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 ----------------------------------- ------- --- -------------- Owner <br /> BY ---- Title ----- �-------------------- <br /> (if other than owner) <br /> FOR .DE iRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ---- ---------------------------------------------------------- DATE _ __ _ - -------------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------ --------------=- ------------DATE -------------•----------------------------- <br /> ADDITIONAL COMMENTS -------- --------- ------------- - - -- - <br /> --------------------------------------------------------------------- ------------------------------ -------------- -------------------------------------------------------------------- <br /> -- ----------------------------- <br /> --------------------------- ------- ---------------------------------------------------------- -------------- --- ---- = ------ <br /> Final Inspection b ______ Date "--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M- <br />