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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- <br /> (Complete In Triplicate{ <br /> Permit No. ...... <br /> This Permit Expires ? Year From Dale 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 .......-. ,:.. ....-. .... ...�-..., !/.-J.. ...... . . ......CENSUS TRACT ....,.... ..............•. <br /> Owner's Name . .. ' �. ....`..a*..L)...�.......... ...............Phone ......... ................ <br /> ....... <br /> CityAddress . . _.. .._.....-- .... ...................... ..................-.........................-....................... <br /> -•..... Phone -------------- ---------------- <br /> R <br /> --- --- <br /> Contractor's Name .---�_-. �. ... ............... ........................................License # ..........-...... ----- <br /> Installation will serve: Residence Apartment House Commercial ❑Trailer Court 0 <br /> ff Motel ❑Other ...................•-•- .................. <br /> Number of living units-1.: ..-- Number of bedrooms __._Garbage Grinder ............ Lot Size ... <br /> Water Supply: Public System and name ............... .......................... ............................................... .......I....Private [ <br /> Character of sail to a depth of 3 feet: Sand b Silt❑ Clay ❑ Peat❑ Sandy Loam lay Loam ❑ <br /> ! Hardpan p Adobe E] Fill Material ...--.....- If yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system in relation towells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available'within 204 feet,j <br /> PACKAGE TREATMENT .[ } SEPTIC TANK f } Size................................................ Liquid Depth ...-...................... �1 <br /> Capacity .-. Ooype ...................: Material...... -..... No. Compartments ...................... J <br /> Distance to nearest: Well ....................................Foundation ................... Prop. Line ...................... <br /> LEACHING LINE [ } No. of Lines ------ g .-..e.......... Total Length-.- -- -. Length, of each line.. --- � 9 ... <br /> D Box .... Type Filter Material ..................Depth .Filter Material .................... ....................... <br /> Qb <br /> Distance to nearest. Well ...... Foundation .,-Pxaperty -Line- <br /> ....... Rock Filled Yea No <br /> SEEPAGE PIT- •[-) 'i)epth Daameter Number".. ....:...- ❑ 0 f <br /> Water Table Depth ----------..................................!,..Rock Size ................................ j <br /> Distance to nearest: Well ----------------------------------------Foundation ...:'................ Prop. Line ...................... ' <br /> REPAIR/ADDITION{Prev. Sanitation Permit ti# ........... -............ Date..............•_---- .....'_.........._..........._._.) <br /> �. � r <br /> Septic Tank {Specify Requirements) ------------------ ---'---------...---......----------------.............----- ................... ..... <br /> DisposalField (Specify Requirements) ....................................... -- -----------------•-•-------------...........-•---.._...----...---.....--•-=--- ---- <br /> ------------------------------ ----•-- ------------------------.------------------------------- <br /> --------- ----- ---.---------------------.---------. -......-----..'�---•-------..-..--------- .-.....-----.......... <br /> - (Draw existing and required addition on reverse side) ? <br /> 1 hereby certify that I have prepared this application and that .the wont 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 /> "! certify that in the performance he work for which this permit Is issued, I shall not employ any person In such manner <br /> as to beco 'ect to Wor 'spe�tion laws of California." <br /> Signed ----- --• - ----- ---- - ---------- <br /> By <br /> -------- = Owner <br /> By -•------- ------------------------------- -•--.._• -------- Title ---------- ... - <br /> (If other than owner) <br /> FOR DEPARTMEN E O Y <br /> APPLICATION ACCEPTED BY --------- --------------- ----- ..-.--. -. � �-77- <br /> �=--..DATE....-.... --�.`-� . --_ - ----- <br /> BIiiLDING PERMIT ISSUED ------------------------- •-... ©ATE <br /> . ............ .... . . <br /> ADDITIONALCOMMENTS -------------- ....... -------•------- ....... ...------..._.... ............. ..................................... <br /> ---------------------------------------------------------------------..-..-----------------•------. -.. ---------••--------------•-------- -----------••------------------------.------- <br /> b <br /> ---•--•-•--------------------------------------------••--------•--••-- ......................................----&RICT . <br /> ..............._.....................------- .......... <br /> ---------•-------------------------------- -----•-- •--•--•-----•---- ---••-- ------------ <br /> -----..- ... <br /> Final Inspection b .Date <br /> Ell 13 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALT DI 8711 3M <br /> i <br />