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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------- 7 .�--6_/_ <br /> �.��---�----------------- (Complete`in Triplicate) <br /> Permit No: --- <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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION » ____CENSUS TRACT -------------------------- <br /> ---- - ---------------------------------------------- <br /> Owner's Name - F%',,z .. , ? `' -._ Phone ----- ------------------------ <br /> Address / v <br /> ,,`tea ,.f-,�.� city <br /> Contractor's Name _art —-----------------------------------------------------------------.License # ------------------------ Phone ---------- ................... <br /> Installation will serve: Residence ❑Apartment House❑ Commercial jMTraile, CWdit ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-.-/------ Number of bedrooms ----!;�----Garbage Grinder ------------ Lot Size ,� 1_4......................... <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;[E <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,) �Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'] Size_ _ Liquid Depth y------------------ <br /> Capacity <br /> lCapacity ------- Type -------------------- Material? ,...t' '__ No. Compartments -.............. <br /> Distance to nearest: WellS747----------------------------FoundationVia------------------ Prop. Line . ................. <br /> LEACHING LINE ] No. of Lines ____/_________________ Length of each line____'_ ---------------- Total Length _ .................. <br /> 'D' Box _Kv_____ Type Filter Material -/,;'T----------- Filter Material __11_----------------------------------- <br /> ------ Foundation -- -------------- Property Line A./-----•-----•-- <br /> Distance to nearest: Well ._4____.___ . . <br /> SEEPAGE PIT k] Depth A'S___________ Diameter ----33------ Number --------2"'----------------- Rock Filled YesM No i❑ <br /> Water Table Depth 1#� Rock Size `jsa-.� <br /> _-_Foundation Pro Line _ <br /> Distance to nearest: Well./�---------------------------------- -------------------- p. �-................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------_-----------------_______---------- Date -___---__-___---__--__-.__-______-) <br /> SepticTank (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 tqJ=xame subject to Wo r an's Co ensation laws of California." <br /> Si n <br /> g - - ----------------------------- Owner <br /> BY ----------------------------------------------------------------------- ---------------------------- Title ---------------------------------------------- ------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- _- ------------------------------------------------------------------- DATE -"1 ° �, <br /> ----- - - ------------------ <br /> BUILDINGPERMIT ISSUED ------------------- ------------------------------------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------- ------------------------------------------------ --------------------------- <br /> ------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------------------------------------------- ------------------------------------------------------ ---- --------------------------------------------------------------------------- <br /> -------------------------------- <br /> ------------ <br /> Final Inspection by: r -- -------------------------------- Date 'r - ------- - - - ------ <br /> ----- - -- - -- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />