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FOR OFFICE USE: 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 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/LOCATION '��_�/�_ _ �_ _ __ _ ____ '-_____- __.__CENSUS TRACT ___ __ __-__--____ <br /> Owner's Name -x+� -_•.._-•------- •--•-------------Phone <br /> �--- ----------- - -- ----------.---•---- <br /> Address � .� City `t --•--M1------------- <br /> Contractor's Name -- ---------------License # -3 Phone ----------------- <br /> r <br /> Installation will serve: Residence [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'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan E ' 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TAN [ ] Size___ ___________________________________________ Liquid Depth _-_--' <br /> K _ ___________________- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -------_............. <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ j r 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 PIT [ ] Depth - Diameter ----------- ---- Number ---------------------------- Rock Filler! Yes ❑ No i❑ <br /> Water Table Depth -------------------------------------------- ..Rock Size ----------------------------- <br /> Distance to nearest: Well .---------------------------------------Foundation -------------------- Prop. Line -----------•--..---_-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --------------------- ---------------------- ---------------------------------------•--------------------- ---------------------------- <br /> Disposal Field (Specify Requirements) __ ____ _______ ___ ___ ___' - -- __--------- <br /> --- ------ r <br /> r�' <br /> --------------------------------= " _ ----� f ----------3 3x3 �---------------- <br /> -- --- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse sside) <br /> I hereby certify that I have prepared this application and that the work will be,done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of.the San Joaquin local Health District. Horne 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 to Workman's Compensation laws of California." ; <br /> Signed --- --------------------- ------ Owner <br /> BY - -- � --- ---------- ---- --------------------------------- <br /> ---------------- ----- Title _L a7,�--"a-� 'e <br /> [if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ --------------------------------- DATE ________-________ <br /> BUILDINGPERMIT ISSUED --- -------------------------------------------------------------•-----------------------------DATE -------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------- --------------- ..---------------- <br /> -- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- <br /> ----------------------------------- -- ----- ---- --------- - ----------------------------------- ---------------------•----------- -------------- 3 - -- --- <br /> Final Inspection by: ___ _ ___ ______Date '7�---- = <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> A <br />