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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----=----------------- - Permit No. -� - -- �=. <br /> (Complete in Triplicate) <br /> --------- -- <br /> ------ ------------------------------------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> I <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 /> ` <br /> JOB ADDRESS/LOCATI N ./_ZaG- ----- .---!.---- ---- --��- ------------ --------- <br /> ---------------CENSUS TRACT <br /> Owner"s Name -- ----- ------------------------------------- -------- ----- Phone ------------------------------------ <br /> Address _ City <br /> r ------------------------ --------- <br /> Contractor's Name --_-- ��" � --- ----- - License # llP 'J__- Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House❑ Comrcial ❑Trailer Court <br /> Motel ❑Other ----- - ------ <br /> Number of living units------- Number of bedrooms ____.Garbage Grinder .NA6)-- Lot Size ________________________________________ <br /> Water Supply: Public System and nam --------------------- l--------------------------------------------------------------------------- ---------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam R <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 placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is available within 200 feet,) f v <br /> PACKAGE TREATMENT [ ] SEPTIC�TAN K,[ Sizef/,2 - --------------- Liquid Depth --- ------------------ <br /> . q <br /> Capacity _IO-- --- Type __--- -- Material__ _.__ No. Compartments __._.._._..__ <br /> istance to neare t: Well ------------------------------------r <br /> Foundation ----«---r----- --- Prop. Line --------'------------ <br /> LEACHING LINE [L/No. of Lines --------- Length of each line-------- .04____-.------ Total Length f`----/aa---------------- <br /> 'D' Box __ .-.____`Type Filter Material _____ Depth Filter Material ------- y--------_--------__............. <br /> Distance o nearest: Well -------XV..________ Foundation ----ZO___............ Property Line ----____-----. ......... <br /> SEEPAt;E PIT [ leDepth __-_-r�' /__ Diameter Number .--------- -f__ -- Rock Filled Yes No C] <br /> Water Table Depth ----------------- <br /> ------------- -7P-------------------------Rock Size -------------- 01 <br /> Distance to nearest: Well --------------/pa__i-----_-----------Foundation ------/-,*-------- Prop. Line ___,.I__________ ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------11 <br /> SepticTank (Specify Requirements) ------ ---------------- -------------------------------- ------------- ---------- ------------------------•---- ---------------------_-- <br /> Disposal Field (Specify Requirements) ---------------------------• -------------------------------------------------------------------------------------------- ----------- <br /> 4a -------------- <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 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 /> "I certify that 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 toWar an's Compensate ws of California." <br /> Signed ---- ------------------------ -- ---------- ------- Owner <br /> BY - -- --------------------------- Title - <br /> (If other t n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- ----------------------------------------------------------- DATE/9-n _d_��y------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ------- ------------------------ - --- - ----------------- -------------------------------=--------------------------- <br /> ------- -- - ------------------------------------------------------------------------------------------------------------ ----------- ------- ------ <br /> ---------- ---------------------- 'I3 --- ------- ---- <br /> ---------------------------------------------------- -- ---------------- ----------- - -- -Final Inspection Inspection bY: ---------------------------------- ------- Date <br /> - - --------- --- <br /> SAN <br /> ------- --- <br /> SAN JOAQUIIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />