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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------- -- --------- -------- ---------- ------------- <br /> Permit No. <br /> (Complete in Triplicate) <br /> ----------------------- <br /> Date Issued <br /> ------------------------ ------ This Permit Expires 1 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�LOCATIO / 7 .�`�G f ---------------------------------CENSUS TRACT .-`S� -----------_ <br /> Owner's Name ------ - <br /> - ---- .-- <br /> Phone ------------------------------------ <br /> ----- ---- = J? City -------- <br /> Address -.- ---------------•----------- <br /> -° lrcZ = --.License # ���------- <br /> Contractor's Contractor's Name ----- --------------- ------ ------- <br /> Installation will serve: Residence Apartment House'❑ Commercial ❑Trailer Court ',C] <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:----1------ 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 ❑ Clay Loam ❑ <br /> Hardpan Adobe ❑ Fill Material ------------ 1f yes,type -----_--_-------------- <br /> (Piot 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 available ithin 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] U Size-- � __- - ------ Liquid Depth ----- --------- <br /> Capacity � C_�_(TYpe �--"---=�-- Material L -t-C'._�- No. Compartments .._- ....-... p <br /> Distance to near A t. Well ------------ ---------------------Foundation ---- - --.-------_ Prop. Line .-. ......... a <br /> DO <br /> LEACHING LINE [ ] No, of Lines -------�---------- Length of each line------ -OD---------- Total Length _- .:.................... <br /> 'D' Box __- -.---_- Type Filter Material _--__ -��---Depth Filter Material ------1g-------------------------------- <br /> Distance to nearest: Well ------ISf�_-------- Foundation ------!_-a_f--------- Property Line .-..�-/_____________ <br /> SEEPAGE PIT [ J Depth -.---- Diameter _ - ----_ Number ----.-- . ----------- Rock Filled Yes No <br /> f tf rr <br /> Water Table Depth --------------7 --- Rock Size -------------- <br /> Distance to nearest: Well ---------------- --------Foundation -_--.---- <br /> gip.--_ Prop. Line ------- ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------.------I <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- •---•--- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------- --------- ----------------- -------------------- -----------------------I--------------------------------------------------------------------------------------------- <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. Home owner or licen- <br /> sed agents signature certifies the following- <br /> "I certify that in the Performa of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to W man's CoriqLpensationlaw of California." <br /> Signed ---- Owner <br /> r <br /> / ` t Title .---- '-----CF:L.�IJ"L�-------------- ----------- <br /> BY -------------------- = IZv h C <br /> (If oth n owner] <br /> FOR DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY ---------------------------------------------------- DATE l-r> ---------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------- -----------------------------------------------------DATE ------- ---------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------- --------------•------------------------------------------------------------ ----------•---------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - --- ----------------------------------------------------------------------------------------------- ------------------------------------------------- ------------------------------------------------- <br /> ---------- <br /> - <br /> Final Inspection by, -------------------•-----•---------------------------------------Date - = ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT W11—bo, <br /> E. H. 9 1-'68 Rev. 5M <br />