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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> ------------ Date Issued <br /> ------- ------- <br /> This Permit Expires 1 Year From Date Issued <br /> - <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 ------------------ - --- --- ------ ------------------------------------- - ------------------------Phone -------------------------- <br /> Address ---- --- - ----------- ------------------------------------- Cii Z4 41)� --------------- --------------- <br /> Contractor's Name C:�:-� -r-s' -----------License # ------------------------ Phone ------------------------------ <br /> -------------------- -------------------- ---------------------------------- <br /> Installation will serve. Residence E"partment HouseE] Commercial 'E]Trailer Court f:1 <br /> Motel F-1 Other -------------------------------------------- <br /> Number of living units:---I------- Number of bedrooms .3______-Garbage Grinder ­:------- Lot Size -------------- ----------------------------- <br /> Water Supply: Public System and name ------------- -- --------------------------------------------- -------------------Private F� <br /> ---------- --------- <br /> Character of soil to a depth of 3 feet: Sand 0 Silt El Clay E] Peat El Sandy Loom E] Clay-Loam E] <br /> Hardpan 0 Adobe Vf�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,) <br /> PACKAGE TREATMENT SEPTIC TANK Size----4_ ---------- Liquid Depth - J -/--------- --------- <br /> LA <br /> Capacity JA�4? a Type q_A0eA­0'4-__ Material- ( <br /> L o. Compartments ---IP <br /> .0 47 --------- <br /> ----- <br /> Distance to nearest: Well ----—-----------------------------Foundation /0--------------- <br /> Prop. Line <br /> LEACHING LINE (i-) ' No. of Lines ----------------- Length of each line---46-1------------------- Total Length ---------------- <br /> 'D' Box 14A4---- Type Filter Material ----Depth Filter Material -------------------- <br /> Distance to nearest, Well ------------------------ Foundation'-_-___________--._____ Property Line ------------------------ <br /> SEEPAGE PIT Depth -------------------- Diameter ---------------- Number ------------------- Rock Filled Yes E] No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size ---------------------------------- <br /> E <br /> Distance <br /> -------------------- <br /> Distance to nearest- Well ----------------------------------------Foundation _,.j---------------- Prop. Line ----------_---------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit#-________---------------------------------- Djtr------------._-_-_--__-_-------] <br /> Septic Tank (Specify Re,quirements)P---------- ----------- -----------------------------------------------------------------------------------------­--------__­------------- <br /> DisposalField (Specify Requirements)"I--------------------------------------------------------------------------------- -------- ------------------------------------------ <br /> I ---------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- <br /> -------------------------------------------------------------------------------------- <br /> -------- ---- -- - <br /> --------- Draw existing and required addition on reverse side) <br /> t <br /> 4 V I I <br /> I hereby certify that I have prepared'this application and that the work will be"done in accordance with Son Joaquin <br /> ..County Ordinances, State Laws, and Rules and Regulations.of the San Joaquin Local,Health District. Home owner or Ucen- <br /> sed agents signature certifies the following: <br /> 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 subjer oporkma 's <br /> ,Comprsation laws of California." <br /> Signed ----------------(�:r--------------------------- ---------------------------------------------- Owner <br /> By ----- - ------------------------------------------------------------------------------------------------ Title - -----------_------------------- ----- ------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY —-------_ ------------------------------------------------------ DATE ----- --- 0-------------------------- <br /> ------ <br /> ------------- <br /> BUILDING PERMIT ISSUED ---<,_�----------------------------------------------------------------------------------- DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -------------------------------- s----------------------=--------------------------- <br /> ------------------------------------------------------------------ <br /> ------------------------ ---------------- -------- <br /> -------------- --------------------------------- --------------------------/-------------------------------------------------------------------- <br /> -- ----------11------------------ - - ---------- Z <br /> - ` ----Z -------- ----------------------------------------- r ----- <br /> Final Inspection by: --- ------- - Date ----O <br /> ---01 1_40--------------------- <br /> -------------------- <br /> SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />