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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete`in Triplicate) Permit No. "---------- <br /> ----------------------------------------- ------------- This Permit Expires 1 Year From Date Issued <br /> 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 .11 -,r"f f' ''---------------------------------------------------CENSUS TRACT _-------------•--------- <br /> Owner's Name <br /> -------11 ---- --------------------------------------J- Phone ------------------------------------ <br /> Address _� Y= --- City fi' ----- --------------------•--•----- <br /> Contractor's Name ------------------------------------------------------------------License # -------- --------------- Phone ------------------------------ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial XTrailer£ewl 0 <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---/------ Number of bedrooms .---!;`----Garbage Grinder ------------ Lot Size ► -------------- ---------- <br /> Water Supply: Public System and name ------------------------------------------------------------------------•--------------------------------------Private'(E] <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;[B <br /> Hardpan Adobe ❑ Fill Material ------------ If yes,type ___________________-__-_-- <br /> (Pilot 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,) %4 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;k Size_P�k e.._ /6- !ALiquid Depth ......V.................. <br /> Capacity _ _____ Type ______________-__-__ Material Vwv ._..e/_ ---_ No. Compartments ................ <br /> Distance to nearest: Well Sr�__________________________FoudationsO__----------------- Prop. i <br /> Line _�__.___,..__....... <br /> LEACHING LINE ] No. of Lines .__ ________________ Length of each line----f_ -------------------- Total Length Z�___-__________._._. <br /> 'D' Box _?'V---__ Type Filter Material _/_�_---------Depth Filter Material _1_-_--______________________--_-- --- <br /> Distance to nearest: Well -.s!7p ___-_----__ Foundation _- -------------- Property Line _r................. <br /> -----•------ <br /> SEEPAGE PIT _k] Depth " ------------- Diameter _--_ ..___. Number . ------ --------------- Rock Filled Yes M No i❑ <br /> Water Table Depth 1.16---------------------------------------Rock Size - `y ^ .'-------.-------- <br /> s a <br /> Distance to nearest: Well/it If ________________________Foundation ---------- Prop. Line I: <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, I shall not employ any person in such manner <br /> as t me subject to Wo <br /> `r , an's Co ensation laws of California." <br /> Sign - ---- - ------ - - -------- ----------------------------- Owner <br /> By - ---------- ------------------------------------------------ -------------------------- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> de FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ___ _________________ _ <br /> ---------------------------------------------- DATE -----------_--- <br /> BUILDING PERMIT ISSUED ------------------------------------------------------ ---------------- - <br /> -- <br /> ---------------------------------DATE ----------------------------------------- <br /> - <br /> ADDITIONALCOMMENTS -----------------------------------------------------------------------------------------------------------------------------------=--------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------------------------- a ------------- <br /> SAN <br /> _ � <br /> �Final Inspection b D _ = <br /> SAN . <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />