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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />............. .................•--......_ ........ __ Permit Na. .7.�i_�.--��... <br /> (Complete In Triplicate) <br /> This Permit Expires 1 Year From batQ issued 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 /> 02-� .. ..............CENSUS TRACT .......................— <br /> ADDRESS/LOCATION .. .�_... _................... ..... , <br /> 1.11 <br /> _... <br /> Owner's Name .... .. ...............• , :.... <br /> Phone <br /> Address .......... ......2,_ ... �'.�-� City .......... <br /> -- <br /> Contractor's Name z... ........... .License # .. .� yPhone ___.._..............-._ ...... <br /> Installation will serve: Residence R Apartment House❑ Commercial oTrailer Court 0 <br /> Motel ❑Other ..................•-----. .................. <br /> Number of living units:....... .... Number of bedrooms -4.......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 LoamKi <br /> ' <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 seepage pit permitted if public sewer is available within 200 feet,) pe <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size................................................ Liquid Depth .......................... <br /> 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 (I C <br /> Water Table Depth ---------------------- .........................Rock Size --------------------------------- OF <br /> Distance to nearest: Well ............. ..........................Foundation .................... Prop. Line ......................'OQ <br /> REPAIR/ADDITION(Prev. Sonitation"Permit# ............................................ Date ....._.._._.._... ................ oS <br /> Septic Tank (Specify Requirements) ..........................---........ <br /> ............................................. <br /> Disposal Field (Specify Requirements) ... --- ------ .....-•-• ......--.._�. ----•-------------- <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 <br /> ollowing:"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 to Workman's Co pensation laws of California." <br /> Signed -----------__--------------------- ------- ---- Owner <br /> By ................................................ <br /> - TItIe ... .......... ......I...... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .............................................................. DATE -------•----------- <br /> BUILDINGPERMIT ISSUED ................•..........................................................................................DATE ...---•------•--..._..--------------------- <br /> ADDITIONALCOMMENTS ........................................................... ............. ------........--•------•----..._.........-----.................•-•--......_..... <br /> ........................... ------------ ................ .................................................... -•------------- ....................... <br /> ------------------------- = D ... <br /> ,1- <br /> ate -17- <br /> -- --- --- ------------------- <br /> Final inspection by: ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r- w 13 24 1.-68 R.,,. SM - — - 7172 3 M <br />