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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- �� Permit No. __ --� './ <br /> (Complete in Triplicate) <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 ismadein compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 7—> o <br /> JOB ADDRESS/LOCATION _1__�S/------ � ! !` 'k - - CENSUS TRACT S <br /> Owner's Name --�'- - --------- ,t .t -'---------- ---- -- ----------------Phone ------------------------------------ <br /> Address --------��• �( J - ------------------------ - -• . City - <br /> Contractor's Name __- � _ - -------License #f ffoP_3.'' Phone _-______-_______--__---_____ <br /> Installation will serve: Residence Apartment House❑ Commercial []Trailer Court ;❑ <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:__ ______ Number of bedrooms __T---_-----Garbage Grinder ________ Lot Size ----.--------------------------------------- <br /> Water <br /> _ ____-_____________________•--.Water Supply: Public System and name --------------------------------•-------------------------------- ------Private RI-11 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ 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 ...................... <br /> Distance to nearest: Well ---- -------------------------------Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] 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 [ ] Depth -----------------— Diameter _______________ Number -.-------------------------- Rock Filled Yes '❑ No <br /> Water Table Depth --- -------------------------------------------Rock Size -------------------- r <br /> Distance to nearest: Well ___--____________--_________________Foundation ____________________ Prop. Line _---___-__.._.__.____. 9 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- -------------------- Date _______-______-_--___-__________) <br /> b <br /> Septic Tank (Specify Requirements) ----------------- -----------------------------------------•_------------------ ----------------------------- O <br /> Disposal Field (Specify Requirements) ---------------- -------------- --------------------------------------------- --------------------------------------------------- <br /> : 1 ----------- � '- �� 't -------------------------------------------- V <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 /> ----- <br /> Title� T-Z - <br /> BY (I other <br /> - n w e ---- ---- -- - "- . , �- ------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ___ _ ___ c <br /> - -- - - - - - - ------------------------------------------------------------ DATE �L- �"'-`.�-�-��------------- <br /> BUILDING PERMIT ISSUED __.____._________--DATE -------------.------------------___--_____ <br /> ADDITIONALCOMMENTS --------------------------------- ------------------------------------ --------------------------------------------------------------------------------------- <br /> - ------------------------------------------------------------------ -------------------------------------- ---------- ------------------------------------------------------- - ------- <br /> ------------------------------------- ------ -- --- - <br /> -- ' - I <br /> ------------------------------------- --- - -- -- ----- - -- - ---- --- - -- - - -- <br /> Final Inspection bY' - ---------------------------------------------------------------------------- Date �%Q- �' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />