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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 Date Issued <br /> --------------------- <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 /> C ' <br /> JOB ADDRESS/LOCATION) - - E r ° h` { = -CENSUS TRACT -- ' ��--------------- <br /> Owner's Name--- - --- = a--==i--� = -'-'---- -- --- ---- Phone <br /> Address G �� J� ----r( City --------------------- --------------------------------------C <br /> �z t s` __' .L_---<— <br /> <�� =1-z_.License # ��Z_>�� Phone .------ <br /> _ ------------------ <br /> Contractor's Name _ _:__ _ <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ---- --------------------------------------- <br /> Number of living units:------(__--- Number of bedrooms ---y---Garbage Grinder ------------ Lot Size .�c _. __�___ ____________ <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 <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 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 /> J <br /> Disposal Field (Specify �quirements) _�:::_� �Yr_ 1l _x z _ ___ - <br /> --------------------------------- <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 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 /> r / ` <br /> By --- ----------------------------- <br /> ----- -------- ------ >_-,� -t 2 �4.L t�—F--------- Title,t_k _ ?Qct t C -------- --- --- ----------- --- <br /> (If other th n owner) r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- Ams: - „A, ,.J...,•v:"= --------------------------------------------------- DATE �------------- <br /> BUILDING PERMIT ISSUED ----- -------------------------------------------- <br /> ------------------------ ----- ------- ------------------------------------DATE -------------------------- -------------- <br /> ADDITIONALCOMMENTS ------------------------------- ------ - -------------------------------------- ----------- ------------------------------------------------- <br /> ------------------------------ --------------------- ---------------------------------------------------------------------------------- ---------------------- --------------- ------- <br /> - ---------------------------- ----------------------------------------------------------------------------------------- ----------------------------------------------------- ------------------------- <br /> ---------------------------------- <br /> ------------------ ------------ ------ --- - -------------------- -- --- ---- ----- ---- <br /> - - <br /> Final Inspection by: •*w `- ---- �' ................................................... <br /> --- . --- --... . . -----------------Date ---- ---------------- <br /> SAN <br /> -SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'66 Rev. 5M <br />