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FOR OFFICE USE: <br /> APPLICATION 1FOR SANITATION PERMIT <br /> ------ ------ - --------- ------------- Permit No. - <br /> (Comisiete in Triplicate) <br /> ----------- hs'---- --- <br /> ___ --------____:-------------------- This Permit Expires 1 Year From Date Issued Y <br /> Date Issued _.1- F' <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 --------- ---- -- - ----------- ------- ------------------CENSUS TRACT> <br /> Owner's Namer------- -- ------------------------------------ r--•---- ----------Phone --I-----_`----.- S-7 <br /> Address -------- ?`�/ - `----------------------------- -------- City -----:5 s_de ---------------------_-------- <br /> Contractor's Name --------------------• --------------------------------------------------------------.License # ----------------------- Phone ------------------------------ <br /> Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court ❑ (�� � <br /> Motel ❑Other .------------------------------------------ <br /> Number of living units:-----._ ---- 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 ❑ 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 p licbsewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size___ _____________ -------- ------------ Liquid Depth _________________________ <br /> O�V <br /> Capacity ° _ Ty "-------�°'_' rial--- No. Compartments _ -''______._.___ <br /> Distance to neares Well _________________________________Foundation ---------------------- Prop. Line -__-______•--_-__---__ <br /> LEACHING LINENo. of Lines <br /> [ ) ---------- Length. of each line____--- __��____-�� Total Length �---�yl_0 <br /> 'D' Box -- <br /> Type Filter Material _':Beppth Filter Material _______�__�_F------------------------- <br /> Distanc o nearest: Well ------�70______-'___ Foundation ---J_6_1---I------- Property Line _______ ___ ___ ______ <br /> SEEPAGE PIT [ ] Depth ---------- Diameter � _ _��____ Number __________ �____ Rock Filled Yes ']�No i❑ <br /> Water Table Depth ----------7--q ....................Rock Siz 4/ , �_ _ <br /> Distance to nearest: Well __-____-1�___--__________________Foundation -----/_0-------- Prop. Line _._.__.5-l--_---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) - <br /> Septic Tank (Specify Requirements) ---------------------------------------------------____--- <br /> Disposal Field (Specify Requirements) ----------- ---------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ <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, 1 shall not employ any person in such manner <br /> as to be4om ect to Work an's Compensation lows of California." <br /> Signed - =/ -----M ---------------- Owner <br /> By -------------------------------------------- -------------------- ------------------------ Title ------- <br /> ------------------------------------------------- <br /> (If other than owner) <br /> FqA DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED BY - DATE <br /> BUILDING PERMIT ISSUED ------------------- ---- -------------------------------------------------------------- ---DATE ---------- :--------•--_------_------- <br /> ADDI 1 NA COMME T <br /> _ : ------------ <br /> ------ ------ ---- -- - ---- <br /> Final Inspection by: -- - ---- - -------------- -------•--- -•--- ---------------Date 1©�V !7---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />