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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .; <br /> ------------------------------------------------ <br /> (Complete in Triplicate) <br /> -------------------- ------------------------------ <br /> Date Issued <br /> ------------------------------- This Permit Expires i 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 complian with County Ordinance No. 549 and'e'xisting Rules and Regulations: <br /> .�Lw� ---------------- ---------------CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCAT ON . f J �f____�-(-r----- ------- --- <br /> 11��� '------ ---------------------------- -------------- Phone ------------------ •-•-------------- <br /> Owner's N me _.___ __ nn <br /> - _ Ci ------------•--------- <br /> - <br /> Contractor's Name ----- ---------- - - - ---- - -- ---- - <br /> --.License # _1�,��3c�rPhone ----------•- ----------------- <br /> Installation will serve: Residence Apartment House <br /> ❑ Commercial ❑Trailer Court 0 <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 lay 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 pla ed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 20 <br /> I 0 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ---------------------.----- <br /> Nj <br /> Capacity ----=--------------- Type -------------------- Material---------------------- No. Compartments ------------------ --- <br /> 1 , <br /> Distance to nearest: Well ___________________________________Foundation -------�___-________ Prop. Line _____________:_---•--- <br /> LEACHING LINE [ ] No. of Lines _______________ ________ Length of each line_.______-------______----___ Total Length ______.____......____._._.-- v <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 E].. No C] <br /> Water Table Depth ------------------- '---------------------------Rock Size ----- -------------------` <br /> Distance to nearest: Well -------------\-------------------------Foundation -------------------- Prop. Line-_---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# ------- `--`--- bate -------•---------------------•--- 1 ; . <br /> Septic Tank (Specify Requirements) -------------- --- ---t` --------------- ------------------------------------ -;---------- ------ - .------------------• � <br /> Disposal Field (Specify Requirements) <br /> ---- ---- -`-v----- <br /> - - <br /> -------------------------------------------------- - -------------------------------------------------------------------- - <br /> f-------- -------- <br /> - -- - <br /> (Draw existing and required addition on reverse side) 4- <br /> I hereby certify that I have prep#;red this application and that the work,�will be done in accordance with:San Joaquin a <br /> County Ordinances, State Laws;'arid%ltules and Regulations of the San Joaquin .Local Health District. Home owner or liven- <br /> i <br /> sed agents signature certifies the following; ,��„ - •' , ' <br /> "I certify that.in the performance of the work for which this permit is-issued, I shaliinot employ any person in such manner <br /> as to beco beet to Workman's Compensation laws"of_Californiq:;''; '- <br /> Signed .............. <br /> . . ---- Ownerl� <br /> '�= -= Title _._ d J:-------------------- <br /> w <br /> --- <br /> --- - <br /> xv— <br /> (If other than owner) '"` `�i �=� <br /> FOR DEPARTMENT USE ON;LY <br /> APPLICATION ACCEPTED BY _ __ r <br /> � DATE ------------ ----•------ -- -------•- <br /> BUILDING PERMIT ISSUED ------------------------------------i I.DATE <br /> ADDITIONALCOMMENTS---------------------------- --------------- ---------•-------------------=------------------------i------:;:--------------- --------- ------------- --- <br /> 9 <br /> --.--_------._________________________________________________________________________._-_____________-__________________-_._________________.___L______---____.__________________-_--______ __________.._ <br /> S <br /> _____________________________________..____ _____ ______________.____ .______'-..________________________----______________________ - � <br /> --- ._ ____ 4_ /-- _ _ ___________- <br /> Final Inspection by: ----------------- ------- ----- Date ___�3 - s- - <br /> - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M � <br />