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FOR OFFICE U E: .. <br /> APPLICATION FOR SANITATION PERMIT <br /> ------ ----------------------- -- - ---------- Permit No, <br /> (Complete itis Triplicate) <br /> ` Date Issued <br /> - <br /> -------------------------------------------------------- This Permit Expires 1 Year From 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 /> JOB ADDRESS/LOCATION sw/ ` - ------------------------------------ ------..CENSUS TRACT <br /> Owner's Name --- .�------------------ -- ----- - - ------Phone --- <br /> Address ---- - Cityc; <br /> Contractor's Name -_---_-_____-_-__-_____.License #o�V.-�` � Phone4_640/10;nZJ,/W/4-_/ <br /> Installation will serve: Residence %Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---- Number of bedrooms __. .Garbage Grinder 4f�__ Lot Size 1f.-'E/`'�__`------------------- <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 rV 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 ----------- ........ ....... <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) ----------------- -----------------------------------------------y °-•-----s-------------------•-------_---•-------- <br /> �jrDisposal Field (Specify Requirements) --- ' ..... . �-�----------- ,� ����/� ----------­--­--------- <br /> "r --------- -------------X T< -----,�, ,� ,. � r �--=------------------------ <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 4hon in such manner <br /> as to become subject to Workman's Compensn laves of California." <br /> Signed ----- ----------- ----- ----------------- - ----- --- --------------------------_._.. Owner <br /> By ----------------------` - -------------------------- Title ------- 0 .... '. <br /> (If r an owner) <br /> FOR DEPARTMENT,USE ONLY <br /> APPLICATION ACCEPTED BY -------- ------------------------- <br /> ' -- <br /> -----. DATE --�1��._ _.1----------------- <br /> ------- <br /> BUILDING PERMIT ISSUED - --------------------------------------------------------DATE ----------- --------------- <br /> ADDITIONALCOMMENTS ---------------------------------------- ---------------------------•---------------------- ---------------------------------------------------- ----------- <br /> ---------------------------------------- <br /> ---------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------- - `----------------------------------------------------- <br /> -- --------------=------- <br /> Final Inspection by: ----- ¢ �� ------------------------------Date -- ja1 <br /> SAN JOAQUIN LO ALIEALTH DISTRi~CT <br /> E. H. 9 1-'68 Rev. 5M R <br />