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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> j ----------------- -- - - , -: Permit No: .��--- - ! <br /> (Complete in Triplicate) <br /> ------------------------ -------------------------------- <br /> ----------------------- This Permit Expires 1 Year From Date Issued Date Issued- -_ j d---7e <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 /> �/ CENSUS TRACT _ --`_ --•-----_-__-• <br /> JOB ADDRESS/LOC �Nl � - -- --- ---- -Owner's Name ---- -- -------- - ---- -----------••------- --- -- - ----:-•--- --------------, --------------------------- <br /> ----------- .....---- <br /> _ __. _____ Phone. <br /> Address -------- - J ----- - - --- --- ---- - ------------- City --- ---------°f --------------------------- <br /> d - License #jf ` �` Phone 1i <br /> Contractor's Name -__ �- 1 <br /> I� <br /> Installation will serve: Residence Apartment House°❑ Co ercial❑Trailer Court i❑ } <br /> Motel F-]Other --------4 -- --- ----- --•------ <br /> k Number of living units'_.__.__ Number of bedrooms --- --- ----Garbage Grinder ------ Lot Size ---------'____________________________- <br /> Water Supply: Public System and name ----------- ------------------------------------------------------- ----------Private El <br />+ Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay F] Peat❑ Sandy,Loam (Clay Loom.❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type -------------__________________ <br /> (Plot pian, 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 see ge pit permitted if public sewer is available within 200 feet,) ` <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size-3-)(1 A___"S_P__________________ Liquid Depth _Y___--______-______-. Q� <br /> VVV <br />[ Capacity .__�°_a_ Type Material____----- No. Compartments ------�._..... <br /> .__ <br /> Distance to neart: Well ___-_____�Aa_=- 4-___-______Foundation ----- ---------------- Prop. line --- <br /> LEACHING <br /> _ <br /> ,� T <br /> LEACH WG LINE [ No. of Lines l.___ Length of each line------ _ <br /> . ____ Total Length ___��___________________ <br /> � <br /> F __________ _:______ �^ <br /> 'D' Box ._._______ - Type Filter Material :__ ttiZ __ <br /> c____-_.Depth Filter Materiali-g___„_________________________ ___• 0 <br /> I <br /> Distance to nearest. Well ___ ___-__ Foundation ____t_II__-_.____._____ Property Line. ___S_.___._____._.___ <br /> I > <br /> SEEPAGE PIT [ } Depth _______._____ ----- Diameter ____ ___________ Number ----------------- ---------- Rock Filled Yes ❑ No <br /> Water Table Depth -------- ----== -' ------------•--------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ____.__.__.... ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------=------------- Date ---------------------------------- <br /> w. R <br /> Septic Tank (Specify Requirements) - -----------------_.------- --- -_--------------------------------------------------------------------�-----------------------•---• ' <br /> Disposal Field (Specify Requirements) -------------- = == .... ------------------------------------------- -------------------------------- <br /> ! .� �r i <br /> ----------------------------------------------- ------;6_�------------------------------------------ ------------------ ------------- <br /> - p <br /> (Draw existing and required addition on reverse side) y " ,..I herebycertifythat I"have preared this application and that the work will be done in accordance with San Jin <br /> County Ordinances, State Laws, and'Rules.and Regulations of the San Joaquin LocalsHealth District. Home owner or licen- <br /> sed agents signature certifies the following: _ w f <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 to Warkm 's Compensa ' s.of California." <br /> Signed ------------------------- 4 = Owner <br /> By ---------------------- - ------ --- ---- --- - - ----- <br /> r Title - ------------------------------------------------ <br /> (If of an owner[ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION-ACCEPTED BYII --------------------------- ----------------- <br /> D <br /> --- ------------. DATE �- ------------------ <br /> BUILDING PERMIT ISSUED .-------= x ------------ --------------------------------------------•-•-------------------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------- ------------------------------------------------------=--------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------- -- - -------------- <br /> __. 1fi <br /> I Final Inspection by: �- - <br /> - ------ --------.Date --------- ---- ---------- <br /> O \ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' E. H. 9 1-'68 Rev. 5M - <br />