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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------- �'----------------------- (Cotinpletean Triplicate) Permit No. ---------- <br /> �'•'t• <br /> ------------------ �------ ---�--- --- ; ./� / <br /> '� _ _________ This Permit Expires 1 Year From Date Issued Date Issued -7? <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 d existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI _------------ - -_�-vl- ----------- - ��_,/ --- - -- ----�-CENSUS TRACT --------------_----- <br /> Owner's Name ----- -------------------- Phone------- -- -.���-------- : � <br /> Address ---------------- � ----- - ------ -- ` f G City /�-- <br /> - License # /- ` Phone1 !'�l' <br /> Contractor's Name ______ ._ <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units:__________ Number of bedrooms _.r2—---.Garbage Grinder /*�7_ Lot SizefA,Q,(---Z_V. ;r-_._....- <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 /> (Pl'ot 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 [ I 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 _-._._._____..._._-I....._................. <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) ----------------- --------;------J--- -------- .........------------­------- <br /> ------------------ <br /> � <br /> Disposal Field k6pecify Requirements) ---------- . ...... ----- /I <br /> �- <br /> � � /. - -----, ---------------------------------------- <br /> ---------------------- <br /> ------------------------------------------ ------------------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> 1 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 /> "1 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 become subject to Workman's Compensation laws of California." <br /> Signed ----- ---------- -------- ------------ ---------------------- ------------ ----.- Owner <br /> ----------- ------- ------ <br /> By --------------- ------- --- ------ ------ Title ---- a_ ..- ------ <br /> (If t han owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------ ------------------------- DATE ._L.-/S'rJ -------- <br /> BUILDINGPERMIT ISSUED --------------------------------------------------------------------------------------------------- ------DATE ------ ----- -------------------- ------ <br /> ADDITIONALCOMMENTS -----------------------------=-- --------------------------------------------------.------- --------------------------------------- --------------------------- <br /> -------------------- <br /> ----------------------------------------------------- - -- -------------- --------------------4.---------------------------------- -------------------------------------- <br /> - ------ - ----- -- - ------------------------ --- ------------------------------------------------ <br /> - - ---- -- <br /> Final Inspection by: ••-----------------_---- / " �--.. <br /> ------ --- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M 0. <br />