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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 <br /> ----_6_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 N . Q �----- � f CENSUS TRACT - <br /> Owner's Name - _ -- ----- ---- �---------------------- -------Phone ------------------------------------ <br /> Address ----------- �e--- -- ---- ---------------------------- --------------------- <br /> - -- -------- - - <br /> .-` = License 13 <br /> Contractor's Name _______W� - <br /> Phone ------------------------------ <br /> - _ ---- _--------- ❑ ❑#Trailer Court ;,E]Installation will serve: Residence artment House Commercial <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 Clay Loam <br /> Hardpan E] 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 seep a pit permitted if publicsewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ SizeZ�__X,�_- fir__________________ Liquid Depth`5_'e_ --------_------ <br /> Capacity <br /> __-_---___,__-. <br /> Ca acit Type _ _.___ Q fi Material_- ________ No. Compartments _______ _ <br /> �Zc�Q <br /> istance to nearest: Well _�✓____.______ ------------Foundation _____ ------- Prop. Line __ ............... <br /> LEACHING LINE [ o. of Li es ------_ ____________ Length of each line____ P__�___.__-_____ Total Length __0 . 4?_..�_________ <br /> 'D' Box ._ .________ Type Filter Material ___ __Z°____Depth Filter Mpterial _____ -_��___........................ <br /> c' <br /> Distance nearest: Well ______ ____________ Foundation ------/0_____________ 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 /> DisposalField (Specify Requirements) ---------------------------- ------------------------------------------------------------------------------------ --------------- <br /> --------------------------------------- ----------------1•-------------------------------------------------------------------------------------------------------------------=------------------------ <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 t Workman's Compensation laws of California." <br /> Signed ----------------------- ------ Own <br /> -------- --- ----------------- <br /> �f' <br /> BY ----- -------------- -------- ---- <br /> l� �j1 ------ Title41 .Q' ,-- --- ---- --------- --------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ----------------------------------------------------------- DATE _j4 -7---- -----•- ----------- <br /> BUILDING PERMIT ISSUED _____-_-______ _____________DATE _.--___________________ <br /> -------------------------------------------------------------------------- ------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------- -----------------------------------------------------------------=--------------------------- <br /> --------------------------------------------------------------------------------------- --------------------------------------------------------------- ------------------------------- - --------- <br /> -------------------------------- --------- ---- ------------------------------------------------------------------------------- / <br /> Final Inspection by- - -- - - ---------------------------------------------------------------------------.Date( --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />