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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------- Permit No. <br /> (Complete in Triplicate) <br /> Expires 1 Year From Date Issued Date Issued __�?_:-_ � <br /> This Permit <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereir <br /> described. This application is made in compliance with County Ordinance No. <br /> 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------- ------------------CENSUS TRACT -_-----.-____---.-.______ <br /> Owner's Name ---- ------ -------------------------------------Phone ?-`'�- 2 .-f__ <br /> Address -------- -------------------------- ------------------------------------------ --. City - W __ ------------------------------- ---------- <br /> Contractor's Name ----- dC=__________________:_--_-.License <br /> Installation will serve: Residence ❑Apartment House❑ CommercialI railer Court i❑ <br /> Motel ❑Other ---------------------------------------- � <br /> Number of living units:------------ Number of bedrooms --_-___.--Garbage Grinder ------------ Lot Size -_✓ �— <br /> --------------------------------------- <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 <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,) 0 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size_- X ----------- Liquid Depth --.- c --------.--- <br /> Ca acit /�_--__ Type t'_C15',%Aaterial-__.._--_-__--_---__ No. Compartments ..--s, <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -_._------------...- <br /> LEACHING-LINENo. of Lin <br /> [ ] es _,3----------------- Length of each line__A0-_-V---------------- Total Length ......... <br /> 'D' Box ---/------ Type Filter Material ///X,0&-Depth Filters Material .___-/_�_,-- ----------------------_-- <br /> Distance to nearest: Well __- - --------.._ Foundation d_------------ Property Line _142------------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes Q No iQ <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 /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------ <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 to become subject kman's Compensation laws of California." <br /> Signed -----r�= '- �` --------------------------------------------------- Owner <br /> BY -------------------- -------------------------------------------------------- ------------------------- Title ------------------------------------------ -------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> c <br /> APPLICATION ACCEPTED BY -----7—,_f-_,__0----------------------------------------------- ------------------------------ DATE - <br /> ----- <br /> BUILDING PERMIT ISSUED --------------------------------------------- ------------------------------- --------------------------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS; ----------=--------------------------- <br /> - - --------- <br /> - --------------------------------------------------------------------- <br /> -- 1 - ____ <br /> - - <br /> Final Inspec i Date _--. .- __` <br /> _ _ ____ ______ _ _______ _____________________________-__-___-_-____ _ 1 -7_ - --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />