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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ---'-` � <br /> ---- -- ---------------------------- ----- ------------- (Complete in Triplicate) <br /> ------------- -----_-- _ o- <br /> Date issued <br /> This Permit Expires i Year From 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 /> is made in fiance with County Ordinance No. 549 and existing Rules and Regulations: <br /> described. This applicationcompliance <br /> JOB ADDRESS/LOCATION rr eC --- ---------- --------------- -------- -----CENSUS TRACT __.----------------------- <br /> Owner's Name .. t Phone ------------------------------------ <br /> Address <br /> , i � __ � i-------rte- - c�tv <br /> �--- ------------•--- <br /> Contractor's Name °t"q°' ----- ---- �i^d = License # -1 Phase <br /> Installation will serve: Residence] Apartment House[] Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other - -----------------------•----------------- <br /> Number of living units-_!------- Number of bedrooms A---------Garbage Grinder ------------ Lot Size -,I&------ - -- -------------------------- <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 ❑ <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity - Type -------------------- Material------------- ------ No. Compartments -----------------:---• O <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------------------ <br /> LEACHING LINE No. of Lines -____----.-__----___- g <br /> - Length of each line---------------------------- Total Length .--- ------ <br /> [ ] <br /> 'D' Box --- ------ Type Filter Material --------------------Depth Filter Material --------------------.---------------------•- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ------------------------ <br /> t" SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ff� ------------- Rock Filled Yes ❑ No 0 1 <br /> WaterTable Depth ------------------------------------------------Rock Size -. ---------------------•------- <br /> Distance to nearest: Well ------------------------------------...-Foundation -------------------- Prop. Line ------------------- <br /> r REPAIR/ADDITION(Prev. Sanitation Permit# -.----�------------------------ Date ---------------- <br /> ----------- -----) <br /> } Septic Tank (Specify Requirements) --------------------------- - , ------------------------------------------------------ --------- .-.--------- --------•-- <br /> I <br /> Disposal Field (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 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 /> "l certify That in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner ` <br /> as to become )e o War man' Co4,,ensation laws of California." , <br /> Signed ---------------- <br /> - <br /> Owner <br /> ------------------ Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , ----------------------------------------------------------------- DATE --7-/2` -- <br /> BUILDINGPERMIT ISSUED ----------------------------- ------------------------------ -------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --------------------------------- ---------------------------------------- <br /> -------------------------------------- ----------------------------------------------------------------------------------------------- <br /> ------------------------------------------ <br /> ------------- ------------------------ -- ----- <br /> - - --------------------- ------------- <br /> ---- ---- - ------------------------------------------- <br /> Date <br /> Final Inspection by: ------ - --------- � /� ---- -- -------- ---- <br /> v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />