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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------- --------------- <br /> Permit No. <br /> - <br /> ---- (Complete in Triplicate) <br /> -------------- - <br /> ---------- ___ ! _ _____-_____ This Permit Expires 1 Year From Date Issued 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 w' h County Ordinance No. 549 and existing. Rules and Regulations: <br /> JOB ADDRESS/LOQ ` __ ----- �^✓----- -- <br /> -_P4SUS TRACT -------------- .......J <br /> .... <br /> 1� • _ Phone <br /> (, <br /> Address - - 1-- <br /> Contractor's Name ---- ------- --------- --- ------ ---` - License # �d�...��-y-- Phone -----•------------••---------- <br /> Installation will serve: Residence C�'Apartment House❑ Commercial [-]Trailer Court i❑ <br /> Motel ❑ Other ----------- ------- = <br /> Number of living units:----/---- Number of bedrooms --- -_Garbage Grinder -------- -_ Lot Size ---- <br /> /—__-............ <br /> Water <br /> - L - <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 ❑ 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 �wer is available within 200 feet,),`// <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[x Size <br /> ;-�-1�-g...�' ---------_- Liquid Depth _T---_-..--------•.._. <br /> Capacity d-D_,-__ Type FA�- "_ Material----4?4_VLA- No. Compartments ---Y............ <br /> J* <br /> Distance to nearest: Well ---------- O._---_-------------Foundation ------/_D---------- Prop. Line ....c5-..,.._._.--... <br /> LEACHING LINE [V No. of Lines ----.----Y----------- Length of each line-----90------------------ Total Length --_ 42-- ---------- <br /> 'D' Box -Unearest: <br /> Type Filter Material ----5__I%---.-•_Depth Filter Material -____-�-�________________--...- -------_sDistance Well -----S�__----_-_-- Foundation _----___ ___-_ Property Line ._..................... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -----------------•-------.------ <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date -___---------------.-____-__-.----) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------•--•---------- <br /> DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- <br /> --------------- <br /> -------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------ - ------------------------------------------------------------------------------------------------------------------------- ------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 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 /> "1 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 become subject to Workman's Compensation laws of California." <br /> Signed -------��""„r`'---------- Owner <br /> - -- - - <br /> BY - -- <br /> `` --- d ' <br /> (If other than owner) V <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------------------------------- DATE ------------------- <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------ ----- -DATE ------------ ------ <br /> ------------- <br /> ADDITIONAL COMMENTS ----------------------------------------------------------------------- ------ ------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- -------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - <br /> ---------------------------------------- - <br /> Final Inspection by: ----- - - -------------------------- ---------------------------------------------Date h`l�' ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> E. H. 9 1-'68 Rev. 5M <br />