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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 6- -----------------�Lt'/ 6' S <br /> rr <br /> (Complete in Triplicate) Permit No. _________ <br /> --------------- ----- -- ------------------------ <br /> ,¢�� � Date Issued <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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._____ 1-_/�__ ._- ..... - - ------ --------- CENSUS TRACT ______________-----_____._. <br /> Owner's Name t -` ---------------------------= ----------- Phonel� 17L7, <br /> Address ---------------------------- v� ��---,, 4 -r------ -- ------ - - City -- ---- ----------------------------------------------- /-------r-- <br /> Contractor's Name --------- -------------------- ------------ -- - ------------------_.License#/X //------ PhoneInstallation will will serve: Residence ❑Apartment House❑ Commercial❑Trailer Court ❑ <br /> r Motel ❑Other -------------------------------------------- <br /> Number of living units:---1_----- Number of bedrooms __A-.--Garbage Grinder ------------ Lot Size -------- <br /> Water Supply: Public System and name ---------------------------- ----------------------------------------------------------------------------------PrivateX <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-.se-wer:is available within 200 feet,) W <br /> PACKAGE TREATMENT [ I SEPTIC TANK[ ] Size-------- ----------- ---------- Liquid Depth __________________________ to <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 0 <br /> Water Table Depth ---------------------------------------- ------Rock Size --------r-------------- ------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...._._.__.__ ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _------------------------------------------- Date _,_,__,____;-------______._______) <br /> Septic Tank (Specify Requirements) -------------------------------- -----------tf - --------------- --------- ----- ----- -------- <br /> Disposal Field (Specify Requirem ts) _____-_- (d----- - <br /> _ ---- , <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------r,___-__--------_______---_--_____-____-___._______ <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 /> By ---------------- -------- - Title ------------- <br /> ----------------------------- <br /> (I other th ner) <br /> ������ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------y�_'-_-_4__U V VA-JL DATE _ -___�- _ <br /> ----------------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED -------------------------------------------------------------- ---------------------------- --------------DATE -------------------------------- ---------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------------ ----=-------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- <br /> - --------- <br /> FinalInspection by: ------------------- V4�- -----------------------------------------------------------------------.Date A_ Z �9-------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />