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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION c-------- -r✓ -------------CENSUS TRACT --.._-------- .--..-..- <br /> Owner's Name ---------G-j1_ lznlG :-------------------------------------------------------- <br /> �---------Phone --------- <br /> --------------------------- <br /> Address �f- ------------------ <br /> S1 ------------------------------ <br /> Installation <br /> - <br /> Contractor's Name ------ ------------------ - ---------License # ----.-------------- Phone ------------------------------ <br /> Inst II ti n will serve: Residence Lmnt House Commercial ❑Trailer Court <br /> ,❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----l------ Number of bedrooms _-'V ..__Garbage Grinder ------------ Lot Size ------------------------------ --- <br /> Water Supply: Public System and name ------------ ---------------------------------- ------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand' Silt F] Clay ❑ Peat E] Sandy Loam E] 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.) ow <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-----------------------------------.------------ Liquid Depth ...------....... ......... h) <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 /> f° <br /> 'D' Box --- -------- Type Filter Material --------------------Depth Filter Material -------------------- .................. <br /> Distance to nearest: Well ------------------------ Foundation ------------------------- Property Line ---------:--------_---- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----.---------.---------..--_-----) <br /> Septic Tank (Specify Requirements) --- --------------------------------------------------------------------•---------------------------,._--------------------- ---- <br /> Disposal Field (Specify Requirements) ----14)xzz.............�f-��----6-mv- ,--------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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 /> "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 to beco a pbgMs' Compens ion laws of California." <br /> Signed ---- ------- -- ------- ------------------------------------------ Owner <br /> BY ------------------------------------------ ----------------------- ------------------------ Title --------------------------------------------------------------------- <br /> (If other than owner) <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- - -------------------------------------------------- DATE ------10� -------------­--- <br /> BUILDING PERMIT ISSUED ---------------------------------------=------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------ ---------------------------------------------------------------------------------- -------------------------------------------------------- ------------ <br /> --------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------- -------------------------- <br /> --------------------------------------------- - <br /> Final Inspection by: -------- C-� Date f <br /> ,/ --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />