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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------- ----- <br /> (Complete in Triplicate) Permit No. ---- <br /> This Permit Expires 1 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 ADDRESS/LOCATION _ ____�� <br /> }�. .-- ----'mss/-�-n---�- - - -----------------------------------------------------CENSUS TRACT ---�_ <br /> Owner's Name ---- <br /> ----- ----- Phone <br /> Address ------------AA- AA84-7------�-� � --------------------------------- City 4k7----------------------------------------------------------- <br /> Contractor's Name ------—- ---------------------- ------License # --------- ------ Phone <br /> ---------------------------------- <br /> Installation will serve: Residence da Apartment 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❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay Loam- -_--.--, -- <br /> f <br /> Hardpan.V Adobe ❑ Fill Material ---.-------- If yes,type ---------------------------- <br /> I (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> N <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ____-------.-------_,_____ 4 <br /> Capacity -------------------- Type --------------------- Material---------------------- No. Compartments ---------------------- <br /> f <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING <br /> ---.----- :--__.---LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ___________,_______________- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------1--l—............... <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ____-___--_ <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(Prey, Sanitation Permit# ____________________________________________ Date __________________________________) , <br /> } Septic Tank (Specify Requirements) --------------------------------------------------------------------------------------------------------------•--------------------------- <br /> Disposal Field (Specify Requirements) ! _______. <br /> ------------------------------------------------------------- ---------------------------------------------------- ---------------------------------------------------------------- <br /> ------------------- --- ------ - -------------------------------------------m--- - <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 /> r <br /> as to be e s bol, ct to 2;rkman's Comp sation laws of California." <br /> Signe ---- -- - ---- - -- ----------------------------------- Owner <br /> BY ---------- ------------------------------ ------------------------------------------------ Title -------------- ---- --- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> C APPLICATION ACCEPTED BY 41kr'.,�------------------------------ ------------------------------------- DATE _'Y dk�-` ------------------- <br /> BUILDING PERMIT ISSUED ---------------- f ---------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS---------- -------------------------- ----------------------------------------------------------------------------------------------------------- - - <br /> -------- <br /> -- - <br /> --- ------- - - --------- ---------------------------------------------------- <br /> - <br /> ------------------------------------ - <br /> Final Inspection by: - - - ---------------------------------- Date f ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT q <br /> I E. H. 9 1-'68 Rev. 5M `V <br />