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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT <br /> ------------- <br /> - <br /> ------�--o-------------- <br /> -------- - <br /> 7Zn <br /> (Complete in Triplicate) Permit No. _ -__-.--. _.. <br /> -----------------------------------------.----------- . This Permit Expires I Year From Date Issued <br /> Date Issued <br /> Application is hereby madeIto the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application ills made infcompliance <br /> �with <br /> hCCounty Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION <br /> �> rr� yr -,�+' - .f�'"' G -- ------------------- CENSUS TRACT <br /> Owner's Name �---- - <br /> ------- <br /> -- ------ ------- --------------Phone <br /> �Address --------- - �-�--- --------- ------- city = ------------------------------------------------------------- <br /> 4 <br /> ------------------- - <br /> - - -- --------------------- <br /> _ <br /> 4Contractor's Name ----- --- License #1"3 Phone ----------- -•-------•------ <br /> Installation will serve: Residence g-A"'partment House❑ Commercial :❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> f <br /> Number of livingunits:---__ ,: Number of bedrooms _ �-�-� <br /> , --- --------Garbage Grinder -------- -.-- Lot Size ------� =- - -�-=--- -------------- <br /> Water Supply: Public System and name ----------------------------"-------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ S;It o Clay ❑ Peat❑ Sandy Loam Clby Loam E]- <br /> Hardpan <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size oflIlot, location of system in relation to- wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: JNoseptic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] i . SEPTIC TANK [ ] Size---------•-------------------------------------- Liquid Depth ---------------............ W. <br /> Capacity -------------------- Type ------------------- Material---------------------- No. Compartments ------ -------•------- W <br /> v <br /> Distance to nearest: Well ----------------------------•----...Foundation -----.-_--------____-- Prop. Line ----------- ...... <br /> LEACHING LINE [ ] No.:l'of Lines ________________________ Length of each line---------------------------- Total Length ___"_______.__".._-- <br /> 'D`!Box ------------ Type Filter Material --------------•-----Depth Filter Material --------------------.-------__-__-_---- _ �1 <br /> Dis. nce to nearest: Well ________________________ Foundation ------------------------ Property Line .....___._______..._.___ <br /> SEEPAGE PIT [ ) Depi h --------- ---------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------ Rock Size -------------------------------- 4 <br /> Distance to nearest: Well ---------------------------------------•Foundation --------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# <br /> -------------- Date ------------------••----- ........ <br /> �l. <br /> SepticTank (Specify Requirements) ---------- ------------------------ -----------------------------------------------------------------------..----------------•-----••-•- <br /> Disposal Field (Specify Requirements} -- -------- ------------- <br /> ----------------------- -r.------- ------- ----f <br /> ------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> 1 (Draw existing and required addition on reverse side} <br /> 1 hereby certify that I have'Iprepared 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 performt nce 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 /> A. <br /> Signed -------------------------- ry[ --------- 1/!1 Owner <br /> By -------------- -------- <br /> ----- Title � ,. <br /> (if other&an owner} <br /> -------------------------------------------------------- <br /> --- <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------` " -------------------------------------. DATE ----" ���-•�- `"---------------- <br /> BUILDING PERMIT ISSUED -1-- -------- ------------------ --------------------------------------------------------- DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS __T-------------------- ------------------------------------------------------------------------------------------------------------------------- --- <br /> I. <br /> ----------------------------------------------=----------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------- <br /> T <br /> ----------- ------------------------- --- --------------- <br /> ,i <br /> ---------------------------------- ----------------------------------------- --- <br /> - <br /> Final Inspection b r Date __-- -- '� ' -------- <br /> _ <br /> -------------------------- ----------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />