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FOR OFFICE USE: <br /> I APPLICATION FOR SANITATION PERMIT <br /> ----------------- <br /> "' (Complete in Triplicate) Permit No_ _________________ <br /> ---------------------------------------------------------- <br /> ------------ -- This Permit Expires i Year From Date Issued 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 ADDRE55/LOCATION 'I-1 .---��---� _/.Lt�6l/ J/-------- --------.-CENSUS TRACT -------------- ----------- <br /> Owner's Name --------� n6� -<_ ,�ff�' `---------------------- - -----.Phone ---------------------•-------------- <br /> Address _ • C._/ , ' <br /> --------- City / <br /> Contractor's Name ..... r"_______________________________.License <br /> _ Phone <br /> Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court ',❑ <br /> M'ofel ❑Other ------------------------------------------- <br /> Number of living units:.- ------ Number of bedrooms Grinder _ Lot Size ----------- <br /> Water Supply: Public System and. name --------------------------------------�'-------------------- - ----------------------------------Privatev <br /> Character of soil to a`depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ -Sandy loam '❑ Clay Loam <br /> ❑ Ado <br /> Hard an " <br /> p 'be ❑ Fill Material .-----__---. If yes, type ---------------�----- --_-- <br /> (Plot plan, showing size olf 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,) 1 <br /> PACKAGE TREATMENT [ ASEPTIC TANK[ ]' Size------------------------------------------------ Liquid Depth ____-.-__--___-_. <br /> Capacity ----------------- Type -------------------- Material------------.--------- No. Compartments -----------.-. <br /> .Distance to nearest: Well -_-___-_____------------•-- <br /> _ _ <br /> _ ____Foundation ____._. _____________ Prop. Line ------------­-------- <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 -------- -------- <br /> SEEPAGE PITth De' r <br /> [ ] p _.____-_-_-- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> r ' ater Table Depth <br /> ----------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------.---.------- <br /> REPAIRJADDITION'(Prev. Sanitation Permit# -------- --------------------i Date --------__.._____-_-______________) <br /> Septic Tank (Specify,Requirements) ------------- - - ------------------ -`------,--------------- --------- . <br /> Disposal Field (Specify. Requirements) ---- / � - ----~-/��-----, jSrA �- ------ f - --- ------- ----- <br /> _ x <br /> ----------= ----X --`----- - - � --------------------------------------- ------------------- ------------------------ <br /> -------------------- <br /> ----------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I hpve prepared this application and that the work will be done in accordance with Sara 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 4hat 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 subject to Workman's Compensation laws of California." <br /> Signed --------?tthan <br /> ----- --------- -- ---- -------------------------------- Owner <br /> BY 1 --- --- Title <br /> --------- <br /> -------------------------------------- <br /> [If owner) <br /> FOR DEPARTMENT USE ONLY <br /> a <br /> APPLICATION ACCEPTED BY ----------------------------- ---------------------------------- DATE . r 7 --------------------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- ---------- ---------------- <br /> ------------------------------------------- - ------------------------------------------------------------------------------------------------ ---------- ----------------�- ------------- <br /> - - <br /> ------ --------------------- - ---------------------------------------------------------------------------- -------- <br /> Final Inspection by- Dates ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `.. <br /> E. H. 9 1-'68 Rev. 5M <br />