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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. .....................� <br /> .................................... .... ............ <br /> --- (Complete in Triplicate) . . ... m -1-- l -. .I. _. - . <br />-----------.......... - <br /> Oate 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 Nor.-549 and existing Rules and Regulations: <br /> / � .......CENSUS TRACT .......................... <br /> JOB ADDRESS/LOCATION ....... ........._ ......._ _ ... F <br /> Owner's Name ......................Phone ..........I...................... i <br /> Address .._..., .. 2•� ..... City .................................................... <br /> License # ..:..................... Phone . -,J.`... <br /> = = .� ` . <br /> Contractor's Nome , - ...................... <br /> Installation will serve: Residence❑Apartment Houseo Commercial❑Trailer Court <br /> Motel ❑Other..-•-....-•--•...................................... <br /> Number of living units:..... Number of bedrooms .Garbage Grinder Lot Size .... , <br /> Water Supply: Public System and name .._.-- .......---.........................•....--...................Private <br /> Character of soil too depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay LoamA <br /> Hardpan❑ Adobe 0 Fill Material ............ If yes,type............... ............ <br /> i <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 700 feet,) <br /> Size.. ? Liquid Depth .... ................ <br /> PACKAGE TREATMENT [ ] . SEPTIC TANK j ] 4C ••- <br /> Capacity . Type -------------•_... . Material----------...------... No. Compartments •-- .....�... <br /> -•f�- <br /> Distance to nearest: Well ----- <br /> ... __....Foundation __._jL�.�...___.... Prop. Line ....... �.--.•• <br /> --- <br /> LEACHING LINE [ ] No. of Lines -------°6 Length of each line----_--- -...._.. Total Length - •- .......... oQ <br /> 'D' Box ----/----- Type Filter Material .........:..........Depth .Filter Material ------------............................... U <br /> Distance to nearest: Well .. _-__............ Foundation _............. ....:. Property Line ........................ <br /> SEEPAGE PIT [ ) DeptF� _ ��iarneter ---------------- Number .._._. .......... Rock Filled Yes ❑ No i❑ <br /> Water Table Depth --------------------------------------r.-.,......Rock Size --- .._ ............ O <br /> .... <br /> Distance to nearest: Well --------------- ............... <br /> -------------------------Foundation ................... .Pro p• Line .................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -..-.------------•------•................... Date ..................................) <br /> Septic Tank (Specify Requirements) ---------------------------- --••-....._...,............------..._.....--•--•---•• ............................ � <br /> ` Disposal Field (Specify Requirements) ------------------- -------" a <br /> ------------ -• ---._.._..--•------•------------- ,.. -- .. <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. Horne owner or Ilcen- <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 to Workman's Compensation laws of California." <br /> Signed ......... <br /> -- -- --- ----- -------------• . ••--- -- -----•----- Owner <br /> BY ------• ----- Title _.._ <br /> --- --- ... <br /> ----- <br /> f (If other t n owner) <br /> R DEPARTMENT USE ONLY n <br /> APPLICATION .ACCEPTED BY --------- ---- -- -•---- --•• ----••--••-------------•-------- =,--------_-.--•--- - - <br /> -_ DATE .1G<11 <br /> BUILDING PERMIT ISSUED •................... . . ..... ............................... DATE ..:_ <br /> ADDITIONALCOMMENTS .......................................----------------------------------------------- ------­­-------L....._........__..--.---...__....._......_...._..... <br /> --------- •-------- - --------- - <br /> i --------- ----------------------------------------- -- -------•--- -------- --------------------------.------_- •------•-- .. <br /> -- ------- ------- ................................. <br /> Date �D 2-Z-7S................. <br /> Fina; Inspection b ---..._ ................•- ---••---- <br /> p Y: ---------- --•-•....... ................ -- . <br /> EH 13 24 1-68 Rev. 5M SAN JOAQ N LOCAL HEALTH DISTRICT 8/7h 3M <br />