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FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT q <br /> ------------------------------------- -------- -- Permit No. <br /> 0 (Complete in Triplicate) <br /> ---------------- <br /> This Permit Expires I Year From Date Issued 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 /> JOB ADDRESS/LOCATION 'I-L-------- ------------- ----------------------------------------- -CENSUS TRACT --•------------------•---- <br /> L .-----V-1y/2zz i__S70-'��--------------------------------------- - ---- �3` o` �5f�----- <br /> Owner's Name _______ <br /> -----phone �-- ------ - <br /> Address � f�✓U/1� _L<(-y'C��� (f CityiC/�-. ------------------------------------------- <br /> _7f�---- �� r �i/ ------- #4 _-�__�_ � � - <br /> Contractor's Name _.- �` ____-__.License _ l Phone ______ ' <br /> Installation will serve: Residence ®'Apartment House❑ Commercial ❑Trailer Court I❑ <br /> Motel ❑ Other -- ----------------------------------------- <br /> Number <br /> f living units: <br /> ' <br /> Number of bedrooms -- � -------------------------------------------- <br /> ____--Garbage Grinder _.__---.---- Lot Size <br /> WaterSu <br /> Pp y: 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,[ ] Size------------------------------------------------- Liquid Depth -------------------------- <br /> Capacity-------------------- Type -------------------- aterial----------- --------- No. Compartments -----•--•-•---- <br /> Distancel to nearest: Well _________________ ________________Fou ation ---------------------- Prop. Line _-________-___-_____ <br /> LEACHING LINE [ ] No, of Lines ________________________ Length f, each line-- ------------------------- Total Length ---------------------------- <br /> 'D' Box ------------ Type Filter Materi ------------------ - epth Filter Material -------------------------------------------- <br /> Distanceto nearest: Well __________ ____________ Fou ation _______________________ Property Line _______________-_._--_-_ <br /> SEEPAGE PIT Depth ___ Diameter ________________ mber ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ------------ --------------------- ------------Rock Size -------------------------------- <br /> Distance;to nearest: Well ---------------------- ________________Foundation -------------------- Prop. Line ----____--__-___-____- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____ ---------------------- ---------------- Date ___-______-__.____________-_______) <br /> SepticTank (Specify Requirements) ----- ------- --------------------- ---------------------------------------------------------------------- ------------•--------------- <br /> Disposal Field (Specify Requirements) ----------------------- --------------------------------- <br /> --•------------------ -------- <br /> 0�x_ ----------------------------------------------------------- <br /> - -�- ---- <br /> --- ill' <br /> I! <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 liven- <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 Wor an's Compensation laws of California." <br /> .- -;----�_ <br /> Signed --- --._ Owner `s <br /> ----------------------- - <br /> By - - ----- --- -------------------- - --------------------------- Title <br /> - -------------- ---------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----= DATE y.` - <br /> BUILDING PERMIT ISSUED ------ DATE <br /> ----------------------------- <br /> ADDITIONALCOMMENTS ---------- ------=---------------------------------•---------------------------------- ----------------------------------------•-------------------- ----------- <br /> --- -------------------------- ---------------------- ------------------------------------ -------------------------------------------------------------------------------------------------------- <br /> - -------------------------------------------------------------------------------------- ---- <br /> --- --- <br /> Final Inspection by: --- - --------------------------- _--.------------- ---------- -----------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />�: E. H. 9 1-'68 Rev. 5M ;i <br />