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FOR OFFICE USE: m, <br /> a -APhICGATIOIW FOR SANITATION PERMIT _ <br /> } (Complete in lripticatel x permit No. <br /> ---------=---------------------------------------------- <br /> Date Issued <br /> --------------------------------------------------------- This Permit Expires it 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 ADDRESS/LOCATION- -- 1J41 ------------- NSUS TRACT <br /> Owner's Name ------------------ -------Phone -------- <br /> ----------------------------------------------------- <br /> ty <br /> Address ---------------------- - i ---------- ------------------------------------------- <br /> Contractor's Name ------------ -------------------------------------------------License # ------------------------ Phone -------------------•---------- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial❑Trailer Court <br /> Motel ❑Other-------------------------------------------- <br /> Number of living units:___________ 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❑ Clay ❑ . Peat❑ Sandy Loam 0, Clay-Loam,❑ <br /> Hardpan ❑ Adobe,(] Fill Material ------------ If yes,type---------------------------- <br /> (Plot <br /> -------------------------_(Plot plan, showing size of lot, location of system in relation for 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,) / <br /> PACKAGE TREATMENT f[': SEPTIC TANK [ ] Sizes___________________ ______ ____________ Liquid Depth ------ <br /> capacity <br /> ----� <br /> Ca aci ' �f^ _ _7 Material___ _l",. No. Compartments _____� <br /> Distance to nearest: Wel! _J_oz_ ------ __________Foundation,_,�,'_-�t-___ Prop. Line __........ .. <br /> ------- --- <br /> LEACHING LINE / "( No. of Lines ----_ _______ Len th of each line_��____y�_hf Y <br /> g Tata! 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 /> Water Table Depth --------------------------- ----------- --------Rock Size ---------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ---------------:---- Prop. Line ------------- -------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------_.-----------------) <br /> Septic Tank (Specify Requirements) --------------------------------------------------------------------------------- -- <br /> Disposal Field (Specify Requirements) _.-•-_________ _ __________ __ ___ --------------- <br /> __ <br /> - - - ----- ------- --- ----- ---------- <br /> --------- ------------ <br /> Pe <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 Co ensation laws of California." <br /> Signed ___ <br /> -- yu----------------------- Owner , <br /> BY �f.[f21gf------------------------------------------- title ------------------- <br /> ---------------------------------------------------- <br /> {If other th n owner) <br /> EPAVMENT USE ONLY <br /> APPLICATION ACCEPTED BY - DATE = = <br /> -- ----------------- <br /> BUILDING PERMIT ISSUED -------- -- ---- ---- --- --- --- --- ----- DATE t <br /> ADDITIONALCOMMENTS ------- -------- ---- --- -------- ----- ---------------•------------------------------------------------..- = <br /> ---------------------- ------- <br /> ---- -- ------- --------------------- ---------------- ----------- <br /> ' , <br /> - ----- ------------------------------------------------------------ ------------------------------------------------- -- - --- <br /> ------------------------------------------------------------------------------ <br /> -- ---------- -------------------------------------------------------- <br /> --------------------------------------------------- ----------- - -- - ---- <br /> Fina! Inspection by: ---------�----------------------------------------- -----------------.Date ---------------------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, ' <br />