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FOR OFFICE USE: <br /> .U_'!5L APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. <br /> Date lsiued -,aC-7,C <br /> ........ This Permit Expires 1 Year From Dat*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 /> JOS ADDRESS/LOCATION ., -._ ..._. .......... - ..... .......... ...... ...CENSUS TRACT <br /> Owner's Name ..................... ...... . ... . .................................------..Phone <br /> Address .......... .... .. _......_ .. City . <br /> . Phone . <br /> Contractor's Nome ._. <br /> ---t- ---��------ --•_ _. . . . . .�-- -- - --• ---------------License � •--------............. <br /> Installation will serve: ResidenceXApartment House j] Commercial❑Trailer Court ] <br /> Motel ❑Other........... ..................... <br /> Number of living units ..... Number of bedrooms ...Garbage Grinder ...... Lot Size ..l .a`` ..1� ....... <br /> Water <br /> Water Supply: Public System and name <br /> r. ...... .. .............Private ❑ <br /> Character of soil to a depth of 3 feet: Sand b Silt❑ Clay ❑ Peat❑ Sandy Loam fl Clay Loam <br /> Hardpan ❑ Adobe;2L,_FlII 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 j ] SEPTIC TANK ] Size--...............­_ ---------- Liquid Depth � <br /> Capacity .................... Type ---•--•-•----------- Material. •-•----- No. Compartments ........V/ <br /> Distance.to nearest: Well ...Foundation ...._._.. Prop. Line ...............I....... <br /> LEACHING LINE ( ] No. of Lines ........................ Length of each line............................. Total Length <br /> 'D' Box ............ Type Filter Material ....................Depth .Filter Material ............................................ <br /> Distance to nearest: Well ------------------------ foundation ----------- ............. Property Line. ............I....... <br /> .... <br /> SEEPAGE PIT j ) Depth -------------­-- <br /> Diameter ................ Number ---._....................... Rock Filled Yes ❑ No E❑ <br /> — _ Water Table Depth ----------------•-. -------------_---- ......Rock Size ..........-....... <br /> Distance to nearest: Well ......... ...... .....Foundation <br /> ---•-------••---•- •------------- ..... Prop. Line ......,............... . <br /> REPAIR/ADDITION 1Prev. Sanitation Permit# ............................................ Date _................_...... ......... <br /> Septic Tank (Specify Requirements( _ .........................• -------------••-•---- - ...,...... '1 " <br /> Disposal Field (Specify Requirements) - r -. <br /> --------------- ---•-- C :-.-�-- <br /> ------------• -M46 � r <br /> .._. <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Herne owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that In the pe ormance of the work for'which this permit is Issued, I shall not employ any person in such manner <br /> as to becoe subject rkman's Compens4lon laws 0 California." <br /> Signed 6-1 ..lirr� -f- C _ " <br /> BY --------------- ------------• Title _...._._ <br /> ......................... <br /> (If other than owner) <br /> FOR- RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __-•-- - - - - -----------------------------------.. DATE ..----1.:.-- G= <br /> BUILDING PERMIT ISSUED _,. _ <br /> --------- --=----------- - _- ----------.DATE . ---.-------- •----: . <br /> ADDITIONAL COMMENTS - - ---• -�•- -•. ......... .........•---•-•--------------....--------------------............-------...-•-------_...._..:...._.._....---.... <br /> ----------------------------••----- <br /> _ ._------- ---------- . -----•....•------------------...-- --------- ........................ ............. <br /> •-• ........ • <br /> --------------------------- .......1. <br /> Final Inspection by: ._-- __-� :,T -------Date <br /> .... <br /> EH 13 .2b 1-68 Ley. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT <br />