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FOR OFFICE USE: t <br /> APPLICATION FOR SANITATION PERMIT <br /> j� -------------°eln `----- Permit No. <br /> (Complete in Triplicate) <br /> 1- ____-----___ ______ This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> 61 <br /> - <br /> JOB ADDRESS/LOCATION .______ ___c ------------- - -------------------------- --- <br /> CENSUS TRACT ___ (1_____________ <br /> ----- --------- <br /> Owner's Name ------------------------------------ ------ _Phone .................................... <br /> Address ----------- OY_c . City ----- ----- - ------------------------------------------ <br /> Contractor's Name �'"� License # ,,25" l7 Phone G1�olv'✓'�14f� <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other --------------------- ------ <br /> Number of living units: , -- Number of bedrooms _ - Garbage Grinder Lot Size ------------------------------------- <br /> Water <br /> -L -%° --------•----.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 sewer is available within 200 feet,) V <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 0 <br /> Water Table Depth ------------------------------------------------Rock Size ----------•--------------------- <br /> Distance to nearest: Well ___________-__________...............Foundation -----------.-------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .--_.__-._____. _____________w'___ Date __________________________________) <br /> Septic Tank (Specify Requirements) --------------------- --- ----- ------------------------------------------ -------- - ------,... -------------- <br /> - - <br /> f <br /> Disposal Field (Specify Requirements) - - - ------7-------- flZ = -- - ---- - --- ----- <br /> �-- --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- - ------ -- ---- - - ---- -- -- �re4uired_ <br /> ------------------------------------ <br /> - --------------------------------------------------------------- <br /> ra xistin aaddition 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 perform ce of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to bec e s bject t an's Co tion laws of California." <br /> Signed _ ___. Owner <br /> BY -------------------------------------- --- ---- itle -------------- ------------------------------------------------- <br /> (If other than <br /> D TMENT USE ONLY p� <br /> APPLICATION ACCEPTED BY ----- - -------------------------------------------------- DATE -------7-- --------------- <br /> BUILDING PERMIT ISSUED ___________ _ _ ✓ _________DATE _____________-___-_______ <br /> -- -- --- - ------- - ------------ -- -------------------------------------- <br /> _ <br /> ADD I IONAL COMM TS __ <br /> ; <br /> ------------------------------ ---------------- - -- --- ---- - -------------------------------------------------------------------------------- -- ------ ---------r-=------- <br /> J�Final Inspection by: ._______-____DateI <br /> J <br /> UIN LOCAL HEALTH DISTRICT c J% <br /> E. H. 9 1-'68 Rev. 5M <br />