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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------- - <br /> (Complete in Triplicate) Permit No --------------------- <br /> ---------=----------------------------------------------- <br /> ______________ ____-._____--__--__-_-_ This Permit Expires 1 Year From Date Issued <br /> 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/LOC T - � __CENSUS TRACT --------------­-------­ <br /> Owner's <br /> .______................. <br /> ----------- ------- -------- ------------------------------------------- <br /> Owner's Name/< nems ---_ 7- -------Phone ---------------------------- <br /> - <br /> Address __________A_______ � __. Cil C - t Y - ------- ---- --- - ----------------------------------------------- <br /> Contractor s Name ---__ ------ -------------_ <br /> -------.License # Phone ------------------------------ <br /> Installation will serve: Residence [A) Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> -- ----------------------------- <br /> Number of living units:___ ----- Number of bedrooms ____Garbage Grinder _.--------- Lot Size ------41 <br /> -___---------_____- <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 '❑ 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 TANK,[ ] Size------------------------------------------------ Liquid Depth _-__-______---_--__----._ <br /> Capacity ------------------ Type -------------------- Material---------------------- No. Compartments ...................... W <br /> Distance to nearest: Well ________-.-_______-___---._____--Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ______________ Length of each line---------------------------- Total Length ............................ 00 <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ____-___-__-_______._____.__..-..-_..._..-- <br /> Distance to nearest: Well -------- --------------- Foundation ------------------------ Property Line --__----_---_._._ ...... <br /> SEEPAGE PIT [ ] Depth .--------_---------- Diameter ---------------- Number ---------- Rock Filled Yes ❑ No C] <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) --------------------------------R-------------------------------- ------------------------ ------ <br /> Disposal Field (Specify Requirements) ---.ez_c"�_ --- -_. �� -- -- - -----� -_ --- ,...�-------------- <br /> ('' , ------- ------------------------ ---------------------------------------- <br /> ------------------------------------- ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------- <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 /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------------------------------------- ----+---- ---- Owner _ <br /> ---- ------ - <br /> B -- - � - <br /> Y - -------- -------------- ¢1----- T ---------------- ------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - ------- --------------------------------------------------------- DATE --------- <br /> BUILDINGPERMIT ISSUED ---- -----------------------------------------------------------------------------------------------------DATE --------------••--------------------------- <br /> ADDITIONALCOMMENTS ---------------- ------------------------------------------ ------------------------------------------------------------- --------=--------------------------- <br /> ----------------------------------------------•---------------------------- ------------------------------------------------------------------------------ --------------------------------------------- <br /> ----------------------------------------- ----------------------- <br /> - ------------------------------ -------------- ---------- --- <br /> Final Inspection by: Date ------------------------------ <br /> SAN JOAQUIIv LOCAL HEALTH DISTRICT <br /> t <br /> E. H. 9 1-'68 Rev. 5M <br />