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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------------------- Permit No. <br /> --- ------�-------------- {Complete in Triplicate) - - <br /> --------=-------------------- -- -- - ------------- <br /> This Permit Expires 1 Year From Date --Date Issued ?--��=".��? <br /> ---_----------------------- ---- ------ --------------- <br /> Application is hereby made to the San Joaquin Local Health District for a per 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/LOCA N -�` ------- CENSUS TRACT -------------- ----------- <br /> Owner's Name --------- -- ---------- ---- - ----- - ------ --- ----------------•--------------------------- ---Phone ------------------- <br /> Address ---//fel I;------ ---x ------------------- City ----------------------------------------------- <br /> •-------- <br /> Contractor's Name # 39_y_ Phone -------------------- <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ <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❑ CI y ❑ Peat El Sandy Loam .0 Clay Loam El <br /> Hardpan ❑ Adobe 'Fill Material ------------ If yes, type ________________________ <br /> (Plot plan, showing size of lot, location of system in relation torwells, buildings, etc. must be placed on reverse side.) 'N� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [-] SEPTIC TANK. ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> P' Capacity -------------------- Type ----------- ------- Material---------------------- No. Compartments ------ _------- <br /> Distance to nearest:,Well ____________________________________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 PIT [ ] Depth ___________________ Diameter ---------------- Number ___ ______-____ Rock Filled Yes ❑ No IQ <br /> T, <br /> Water Table Depth -------------------------[----------------------Rock Size ------------------------ . <br /> I4 Distance to nearest: Well ----------------[----`-----------------Foundation -------------------- Prop. Line -------•-------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---------------------------------- Date ---------------------------------1 <br /> SepticTank (Specify Requirements) --- ------------------------------------------------------------------------------------------------------------------------------------•-- <br /> Disposal Field (Specify Requirements) - t -- ------ <br /> --------------------------------------------------- ------------------ - <br /> (Draw existing and required addition on reverse side) 1 <br /> I hereby certify that I have prepared this application �nd 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. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify t a"n the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to b ome s bl ct to Workman's Compensation laws of California." <br /> Signed --- - -- Owner <br /> ------------- <br /> BY <br /> 7itle u-t� <br /> (If other than owner} <br /> FOR DEPARTMENT USE ONLYoe <br /> le9 AV <br /> ? <br /> APPLICATION ACCEPTED BY ---- ------------------------------------------------------- DATE --/ M: -------------- <br /> BUILDING PERMIT ISSUED ------- ------------------------------------------------------------------------------- --- ---DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ----------------------------- _:.---------------------- ------- -------- <br /> ------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------f-- ----------- <br /> -- --- ------ --------------------------------------- -------------------------------------------------------- - ------------------------------------------------------ <br /> ; <br /> ---------------=--------- --------------- ---- - ---- � <br /> -------- <br /> 06 <br /> - -----------te - QFinal Inspection by = <br /> �/'SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />