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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No:41"AA <br /> -------------------- <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> 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 /> /i � - 5' � <br /> JOB ADDRESS/LOON !__ -- ---------=----------------------�,"��`/z�t CENSUS TRACT <br /> Owner's Name - - - --------=---------------------------------- y� ----------Phone <br /> Address -----------// S$ 5 -- � f -- ---- . Cit Gam'`_--�� <br /> Contractor's Name -- ----- ---- --- --�-� -- ------ ----- "`4� -,License # Phone <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court i❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:------fir.... Number of bedrooms __-------Garbage Grinder -------- Lot Size -------------------------------------------- <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•❑ Fili Material ____________ if yes, type __________________________ <br /> (Pl'ot plan, showing size of lot, loccition 6f,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------------------------------------------------ Liquid Depth -------------------------- �Pwo <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ ----------: <br /> Distance to nearest: Well ---------------------------- <br /> ----------Foundation -------i-------------- Prop. Line .------------ ........ lS1 <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 ------------------------- <br /> Property Line ______-____ <br /> SEEPAGE AIT [ ) Depth __________________ Diameter ______________ Number ---------------------------- Rock Filled-.,.Yes ❑ Na iQ <br /> 05 <br /> Water Table Depth --------------------------------------------- <br /> ----------------------------------------- ---Rock Size -------------------------------- <br /> Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line ---------------- <br /> REPAIR/ADDITION{Prev. Sanitation Permit# .__--�:------- --------.- - __-_=—tJate. __________________________________} <br /> Septic Tank (Specify Requirements) ------------------- ------- - - <br /> _. - <br /> -- -- ---- ----- <br /> Disposal field 711ycify Requirements) --- ---- -_._,::-. -_:::__ _- --- - -- -------- <br /> -- <br /> --- ---- - <br /> -- <br /> r _ <br /> -b - - -.. . . ------- -------------- - -------- - 33- ------------ <br /> ---- <br /> X- s---- ----- ---------------------- ---------- ---- ----------------------------------------------- ------------------------------------------------------------------------------------------ -- <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'"Jaaquin Local Health District:Home owner or licen. i <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 law of California." <br /> Signed ----------------------------------- <br /> ---------------- -- -- ---- ---�,.,r -----..�..�_wner_...._�....� �..._....,._ _... <br /> -- --- ------------ -- ---- - -- - - - ---- O <br /> BYC:�, -' Q Title ----------------- - -- --------- - --------------------- <br /> {If other than ow o <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ----------------------------------- DATE ---------------- <br /> BUILDINGPERMIT ISSUED ------ ------------------------------------------------------------------------------------ ---- ----- ---DATE ---- ------------------------ ------------ <br /> ADDITIONALCOMMENTS --- ----------------------------------------------------------------------------------------------------------------------------- -------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- - - ---------------------------------------------------------------------------------- - <br /> Final Inspection by: ----f�: --—----------------------------------------------------------------- ------ <br /> SAN <br /> ----SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />