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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------ Permit No. W-fD <br /> lComplete in Triplicate) <br /> r Date Issued <br /> -------------- -------___ This Permit Expires 1 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 /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> - <br /> JOB ADDRESS/LOCATION .,.---�—--- %J -,i _ -------- <br /> CENSUS TRACT TRACT ----------------•--------- <br /> .Owner's Name �� �f__ - <br /> Address ���� ° 3 City - ---------------------- ----------•-•----- <br /> Contractor's Name - L"► t �l.,re`- � ' --------License # -a `�/�� ---- Phone <br /> Installation will serve: Residence -]Trailer House❑ Commercial ❑Trailer Court ❑ <br /> / Motel ❑Other ---------------------------------------- i <br /> Number of living units:----- Number of edro ms ...Garbage Grinder ------------- Lot Size --- ` "<1e_e•------------•----- <br /> Y ------------L�._.�---- <br /> --------•-------_- --------------Private ❑ <br /> Water Supply: Public System and name - ____ 1 <br /> Character of so!I to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ <br /> s <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: t (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ I SEPTIC TANK f J Size------------------------------------------------ Liquid Depth -------------------------- <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 /> '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 J❑ <br /> WaterTable Depth ------------------------------------------------Rock Size --------------------------•----- <br /> Distance to nearest: Well ---------------------•------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIRJADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------- -------- - ------- --- ------------------ <br /> Disposal Field (Specify Requirements) _ _A= '4*j----------- <br /> ------------ <br /> F -------------- --------- <br /> -- - ---------- ---------------------------------_--------------- <br /> Ujr <br /> IJ / <br /> (Draw existing and re ired 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 subiect toOWorktnan's Compen tion laws of California." <br /> Signed '� Owner <br /> Byr title ------- ---------------------------- ---------------------------------- <br /> (If other than owner) 61 <br /> FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY ---- ------------------------------------------- DATE _ ------------------ <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------- -----------------------=----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------- <br /> ' -------- ----------------------------- _ <br /> ---- <br /> ------ -- <br /> -Date _� - -Final Inspection by ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />