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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. .-6�-` <br /> (Complete in Triplicate) <br /> ____________------------ -- This Permit Expires 1 Year From Date Issued Date Issued <br /> 'r <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 /> . Zf 2 <br /> JOB ADDRESS/L TION - /_T r - ------ CENSUS TRACT -------------------------- <br /> Owner's Name .__ __.. <br /> -------------- --------------------------- _ Phone ------------------------------------ <br /> Address ------------- - - --------- 'T 34k ----- - -------------•-- City <br /> �� ¢ <br /> - --------------------------- <br /> Contractor's License # �� .. _ Phone <br /> Name ___-__--. _ ____________ ____ _____;�Apartment <br /> ❑ ❑ ❑ <br /> Installation will serve. Residence House Commercial : Trailer Court <br /> Motel ❑Other ---- --------------- <br /> Number of living units:---- ------ Number of bedrooms ..Garbage Grinder ------------ Lot Size ----- --- ------- ----- <br /> __WatWater <br /> er Supply: Public System and name ----------------------------------------------------------------------- ---------------------------------------Private <br /> Character of soil to a depth of 3 feet:,,-..,Sand'❑ Silt❑ Clay E] Peat❑ Sandy Loam -E] Clay Loam ❑ 4 <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 tank or seepage pit permitted if public sewer is available within 200 feet,) ' <br /> PACKAGE TREATMENT [ I SEPTIC TANK?[ ] Size------------- -------------------------------- Liquid Depth --------------------------- i <br /> r � <br /> Capacity -----------------•-- Type -------------------- Material---------------------- No, Compartments ---------------------- <br /> Distance to neare_st:,:Well ------------------------------------Foundation ---------------------- Prop. Line ------------•--------- k <br /> LEACHING LINE [ ] No. of Lines _ --.._-Length,of each line-----------------------_--- Total Length .-.___.___-_ <br /> a I '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 ID <br /> Water Table Depth _ ` '----------------------•--- -------------Ro c C Siz-a:-------------- <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 /> Ir F R <br /> r-----------�--------- <br /> ------------------------ ---- sa <br /> --------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) Q <br /> I hereby certify that 1 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. Horne 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, 1 shall not employ any person in such manner <br /> ' as to become pbtect to Workman' mpensation laws of California." <br /> Signed -- /1---- --- ------ --------- --------------------------- <br /> ------- A----- ---- -------------��- ----- Title <br /> c--------------------------------- <br /> By <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------- --------------------------------- DATE -/-0-. ------------- <br /> BUILDING PERMIT ISSUED ----------------- --------------------------------- ------DATE ------------------------- <br /> ADDITIONALCOMMENTS ------ ----------------------------------------------------------'------- ------------------------------------------------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- ------- <br /> --------------------------------------- - -------------------- <br /> - <br /> Final Inspection by: -------- `� r --------------------------•-_--- ----------------------------- Date/� -�--f------•- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />