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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _n <br /> ---- - _'�/_'�� <br /> � \ (Complete in Triplicate) Permit No: - _ � <br /> ---------------------------------- <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 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/LOCA ON .Z- 16e---------------------- -----------------CENSUS TRACT --------------------- ---- <br /> Owner's Name - - - - --------- ------------------- --------------------------------------------Phone <br /> ------------------------------------ <br /> Address ------7-7 S -'�---- - / ------ City <br /> _ License # ` :'Phone --- -------------_---------- <br /> Contractor's Name - --- --------- �" '�` MOO- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court I❑ <br /> Motel ❑Other ------� --//-- --------------- <br /> Number of living units:------I____ 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❑ Silt❑ Clay ❑ Peat❑ Sandy Loam �ay 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 f ] Size----------------------------- ------------ Liquid Depth . <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ...................... 1 <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 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 /> ---------- - �. ' = �'�''/--`--------�� ' -4- u - - -a.--�---- <br /> ----------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 th ' the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to b ____u <br /> lett to Workman's Compensation laws of California." <br /> Signe -------- ------ ------- ---------------------------------------------- Owner <br /> By -- 1�--+�,r.. =- . -------- a Title f . <br /> of other than own r) 1 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY/.,__;_ _ --------------------------------------------------- <br /> Y . __ _ _-__. DATE 9___________________ <br /> BUILDING PERMIT ISSUED --------------------------------------------------------------- --------------------------- --------------DATE <br /> ADDITIONAL COMMENTS --------------- -------------------------------------------------•---------- ------ <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- - - --------------------------------------------------------------------- <br /> --- ---- --- - --------- <br /> - -- - -- -- -- - - <br /> Final Inspection by . !__ _. __ __ __ _ _ __ _ Date ."' ________ <br /> -- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />