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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <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 /> o� ,/ � �` ----- CENSUS TRACT ----------------- _----- <br /> JOB ADDRESS/LOCATIO - <br /> - -- ------------------- -------------- <br /> Owner's Name --------- ------- --------- - -- -- ---- ------------------------------------------------ -------- --- ,--�ne .------------------------------- <br /> //-B-021__ - !� '�` _-. cit ---------- ------------------- <br /> Address !_� -------- -- -- Y ------- _ <br /> Contractor's Name -- <br /> - - License # ? Phone --------------- <br /> Installation will serve: Residence OApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- / <br /> Number of living units:------- Number of bedrooms ----- .____ arb ge Grinder ___--_---- Lot Size __,��`-----_�`��----______________ <br /> ------------------------Private <br /> Water Supply: Public System and name -------- - - ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeX 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 ...................... <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 /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ._.................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------- ------ <br /> ----------------�-------- ------------ -------�--------- - �----F'�, �-- <br /> ; <br /> �D <br /> ments) ------- �- ------ <br /> Disposal Field (Sp@ - y Req -re <br /> lop <br /> -eW-- $ 0---- <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 be a su �ect`to W rkm s Compensatio aws of California." <br /> Signed ------ ------ <br /> - <br /> Owner <br /> BY ----------------------- - -- - - ---- <br /> ------------ Title -------------------------------- ----------------------------- --------- <br /> (If other her) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ----------------'-- V DATE [ `q-------------------- <br /> BUILDING PERMIT ISSUED ----------- ------------------------------------------------- --------------------------------------------DATE - ----------------------------- <br /> ADDITIONALCOMMENTS -------------------------------- --------------------------------------------- ---------------------------------- ---------------------------- ------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------A-------- <br /> I { <br /> --- -------- - - -- ------------------------------------------ -t-- ---- - - -� - <br /> Final Inspection by: ------------------------------ ��� = -`A ------------------------------- -------------------Date I%� - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. W. 9 1-'68 Rev. 5M <br />