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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------- ---------------------------- Permit No. <br /> (Complete in Triplicate) <br /> _-------_---_--_---_-------_ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> ------------------------ <br /> Application is hereby made to the San Joaquin Local Health District for a per 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/LOCA?. N ��7 - -- -------------- - -`. CENSUS TRACT <br /> Owner's Name --------- - Phone ------------------------------------ <br /> Address ---------------------- -----r�-- t City i�.� ------------------------------------ <br /> -. t <br /> / E ' <br /> Contractor's Name - = ¢��� _ .License # �� Y__ Phone ---- ---------------------- <br /> Installation will serve: Residence MI(partment House-[] Commercial:❑Trailer Court ;❑ <br /> t <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units ------ Number of bedrooms ____Garbage Grinder ------------ Lot Size _ ___ ____-_ ____ --____ <br /> Water Supply: Public System and name --------------------------------------------- ---------------------------------------------------------------.Private LyJ' <br /> Character of soil to a depth of 3 feet: Sand'E-] Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam.[] <br /> Hardpan Adobe-E] 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 /> �✓ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) \ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size_________________________ ______)` _ Liquid Depth -------------------------- <br /> Capacity <br /> -------------------- Type -----------------_ Material--t---- -- ------ No. Compartments <br /> � s <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----__--.__.:_------- <br /> LEACHING LINE . [ ] No. of Lines ----------------- <br /> Length of each line------ ------------------- Total Length -----------------._.._---____ ' <br /> 'D' Box --- Type Filter Material --------------------Depth Filter Material -------------------------------------- <br /> Distance to nearest: Well ________________________ Foundation ._._--_--- <br /> ---- Property Line _.___ _.__-_.___ <br /> --- <br /> _ ---- <br /> SEEPAGE PIT [ j Depth ________________`,_Diameter ---------------- Number _ Rock Filled Yes ❑ No C] <br /> Water Table Depth -----------------------------------------------Rock Size ----------------------------- <br /> k <br /> ----------- -------- <br /> k Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop.. Line ------_-------------- <br /> ,. s <br /> REPAIR/ADDITION(Prev. Sanitation Permit#----------- ------------------- Date ------------------------------_---1 �.,. <br /> Septic Tank (Specify Requirements) -------------------------------------- ---- ----- --- -`-- -----:----------------,---'- --- -------------------- <br /> oti.. <br /> Disposal Field,(Specify Requirements) ------ --------------------------------- -- --------- <br /> ' ---- ------------------------------------------ ---------=-------------- <br /> ----------- <br /> -------------=------------------------------------------------------------------------------------------------------ -- <br /> s <br /> (Draw 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 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 s ject to Workman's Compensation laws of California." <br /> Signed ------------ -- ---------- -- -- --- --- ---- ------- ------------------- Owner , <br /> By ------------- ------- ---------------- Title <br /> - ------- ------------------------------------------ <br /> (If�-ther than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------- -----------• DATE _!r�!-� '/�r0------------------- <br /> BUILDING PERMIT ISSUED -- --------------------------------------------------------------------- - <br /> ------------------------------DATE .------- -------------- - <br /> - - <br /> ADDITIONALCOMMENTS ----------------------- -----------------------------.- --------------------------------------------------=---------------•----------- <br /> -------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------- - ------ ------ <br /> --------------------------------- r------ - ---- --------- <br /> Final Inspection by: ---------------------------------------------------------------------------.DatQ-` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M t <br /> a <br />