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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------- Permit No. . <br /> ''� (Complete in Triplicate) � i <br /> i <br /> {..�'} Date Issued <br /> --- ----------------- ---- -- 1 v .--__.....- 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 /> dr��JOB ADDRESS/LOCAtIN _ _- `" - CENSUS TRACT __.. ._..Owner's Name ------- ;_/ <br /> - --------------------------------------------------- - ------- -- --Phone ---------------------•-------------- <br /> Address ------------------- ---- + --'- '- CitY�� e � <br /> Contractor's Name ___ __ �° ____.-_____..__.__License # -_cF_ Phone <br /> V <br /> Installation will serve: Residence ❑Apartment House Ig Commercial ❑Trailer Court !❑ <br /> Motel ❑Other ------- -------------- �( <br /> Number of livingunits:____ Number of bedroom Gar age Grinder __-__-__._ Lot Size ._____-_-_._ -_- <br /> ... /�Cl l-- <br /> Water Supply: Public System and name ------------------1 ------[� ----------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 171 <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] 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# ____________________________________________ Date _.__-_--___-----.-_.-__.____-___..) <br /> Septic Tank (Specify Requirements) ---------------- - --- ------ ------------------------------------------- -- ----- }r -------- ----- <br /> Dispos .I Field (Specify Requirements) -__ -.-��-- =----- <br /> L <br /> - - --------------------- ----- <br /> am <br /> ' <br /> T7c'A rqt9r--------------- <br /> --------------------/ =� --- ------ <br /> (Draw existing an required addition on reverse side) . <br /> I hereby certi t at ave prepip red 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 performa cel of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to be e s bject to , or man's Com e� tawsgf California." <br /> Signed--- -- -- Owner <br /> By __________________________________________ ____ ______ / _----_--_-.._.-._-...___-..-.._..--..__.____-_______--- <br /> (If other than o <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- -------- DATE <br /> BUILDING PERMIT ISSUED -------------------------------- ---- -- -- - --------------------- -----------------------------.DATE - ----- --------- ------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------- ---------------------------------- --------------=--------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------- --------------------------------------------------- ---------------- <br /> -------------------------------------------;_ <br /> ------------------------------------------------------------ ---- - ........ <br /> - -- -------------- - <br /> Final Inspection b .____ __ __. __ - Date _ -----_..- <br /> ---------- <br /> SAN J AQUIN LOCAL HEALTH DISTRICT f�< <br /> E. H. $ 1-'68 Rev. 5M <br />