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FOR OFFICE USE: <br /> > / APPLICATION FOR SANITATION PERMIT <br /> ! Permit No. ---�7 ..� <br /> (Complete in Triplicate) ` ��,fL_ ��/ <br /> .....................I............... Date Issued .................... <br /> This Permit Expires 1 Year From Date IssuedI <br /> Application is hereby made to the-San Joaquin Loco] Health District for a permit to construct and install the work herein <br /> described. This appiication,is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS LOCATION .................... ........CENSUS TRACT <br /> s <br /> Owner's Nome _..We— ---------•--•............................................: ..........Phone ..................................-- <br /> Address ............ ��------ ------- -......I City ........... ................... <br /> Contractor's Name .................License Phone �x�=. ���. <br /> I <br /> Installation will serve: Residence Apartment Hou"Se0 Commercial [Trailer Court 0 <br /> ''. Motel ❑Other .................. <br /> Number of living units:...___.._ Nuniber 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 /> Hardpan ❑ Adobe 0- Fill Material ':-•---•---- If yes,type ---------------------------- Q <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 TANK,[ ] Slze.....................•_......--:_...._._....-_.. Liquid.'Depth Length Total ---......__.---.._.........__ <br /> . <br /> _....._ ' <br /> ;Capacity ...............L.._`_ Type...................... Material..._....__ __-e: No. Compartments ...................... <br /> Distance to nearest: Well '`� _ .:.'Foundation <br /> Prop. Line ...................... <br /> LEACHING LINE No. of Lines ....... t <br /> ... Len th of•each•-l : ._.: <br /> ine- 3'' ..:,...... ........ T g[ ] ....... .`•�--- � �� 9 �---�-� ••----- -•..--•--•--• <br />` D' Box Type Filter,Materiai `_.-....~ `'6Depth Filter Material <br /> Distance to nearest: Well ........................ Foundation <br /> ........................ Property Line ................ <br /> SEEPAGE PIT [ ] Depth .................... Diameter ................ Number ---_--------------------.. Rock Filled Yes [❑ No 0 � <br /> Water Table Depth ..Rock Size <br /> Distance to nearest: Well ----------------------- .................... Prop. Line -----_.____._. ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------• ----------- Date ...•-------_'---L................. <br /> ) <br /> Septic Tank (Specify Requirements) ............... ......................... .......... <br /> Disposal Field (Specify Requirements) •-s�•.t /�`-- /- --- - ---- -----s��i -- -_ _.f/_ .f!......................... <br /> --------------------------------------------- .._... ..- . ------...---------------­­...............-................... .............................. <br /> i{ (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 /> as to become subject to Workman's Compensation laws of California." <br /> a <br /> Signed .__.... . ..............••................---- Owner <br /> BY ..__... ------------------------------ Title _ .. _004w,-------------------------------------- <br /> t <br /> (If of t on owner <br /> FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY -•-----•---: �--<•-••-��--_-��?•--,----'�- ---�-=-•----------------•',•--....--••-•--•--•--....._. DATE ���,�!;t_.`�"_�_.�•--....._..... <br /> BUILDINGPERMIT ISSUED ................... ......................................................................................DATE ...--------........_. ........... --------- <br /> ADDITIONAL COMMENTS ................................................: <br /> ' .......................................................1 � ----_._.._ <br /> . .. ........ <br /> ..................... <br /> ::::...: ::::: ................................................................ <br /> ..:..:..::: - ---- <br /> ------------------------------------- ----•--------- --•• •-...... --- _ ---- <br /> Final Inspection by: ._ Date .�/2 �,P�� ............ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -Ylin 1 u <br />