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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - --- ---------------------------------- <br /> ---------------- (Complete in Triplicate) Permit No: ....... <br /> - _ This Permit Expires f Year From Date Issued <br /> Date Issued .--. <br /> ----- ------------------------------ <br /> --------------_ <br /> Application is hereby made to the 'San Joaquin Local Health District for a permit to construct and install the work herein <br /> 4escribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: i <br /> JOB ADDRESSAOCATI - - -------- -� --- - -- ..:--- --.-CENSUS TRACT ------------- <br /> Owner's Name .--------- �}4 !' -- ` Phone �`- - - �-- ------ <br /> Address ------------------ = p-` «1" - a------------------------------------ City i <br /> r .=------------------------------------ ; <br /> Contractor's Name --- - ------ ---•-- - ----- -----`,- G`ai/-------------'-------------License #fes-5-11- Phone V6- -___Yj6_0� '• <br /> Installation will serve: Residence ❑Apar'tment'House❑ Commercial :❑Trailer Court 1El- <br /> Motel ❑Other ---------off <br /> Number of living units:------------ Number of bedrooms --------_-.Garbage Grinder Lot Size ---__------------------------------------- <br /> Water Supply: Public System and name ----------------------------------------=-------------------- - l'C.�--------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay €❑ Peat❑ Sandy Loam ❑ Clay Loam' <br /> Hardpan ❑ AdobeFill Material ------------ If yes,type ---------------------------- <br /> (PlotP Ian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> - '-�- <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is availaable-within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK'[ ] Size-----------------------------------•------------ Liquid Depth -------------------------- <br /> Capacity -------- --------- Type -------------------- Material- 7'No. Compartrnents ----------------------- <br /> Distance to nearest. Well -------------------------------- .Foundation ---------------------- Prop. Line ...._--_-_---_-_-_---. <br /> LEACHING LINE ( ] No. of Lines ------_--- ------------ Length of'"each line---------------------------- Total Length ----------- ---------------- <br /> 'D' Box ---I---. --- Type Filter Material ________________t-.Depth Filter Material ___-_-=---`________.__________._.________._ <br /> Distance to nearest: Well.."---------------------Foundation ----------------------- Property Line <br /> SEEPAGE PIT [ ] Depth ----�------------------Diameter ---------------- Number ------------- Rock Filled Yes ❑ No i❑ <br /> ..,..� ,. Water Tab,le.Depth ------------------------------------------------Rock Size ---- --------------------------- <br /> i <br /> 'Distance to nearest: Well ----------------------------------------Foundation -------_------- ---- Prop. Line -----............ <br /> REPAIRfADDITION(Prey. Sdnita#ion,Permit=# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> --------------------- -----------Septic Tank (Specify Requirements) ------ ----- ----.------ ------ <br /> �] r � �} <br /> Disposal Field {Specify..Requirements) --------4�rdef- -���� <br /> ------------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------- <br /> ---------------------------------------------- <br /> I (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. 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 subject to Workman's Compensation laws of California." <br /> Signed -------- -- - - --------------------------------- Title---------------------------------- Owner <br /> BY ------------- -- - -- <br /> - -- <br /> 44------ ----- ------------- <br /> (If other an owner)! <br /> _ OR DEPARTMENT USE ONLY <br /> is APPLICATION ACCEP ED BY --- - ------------------------------------------------------------- --------- DATE - -2- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------=--------------------------- <br /> ---------------------------------------------- -- - ----------------------------- <br /> ------------------------------_---- -------------------------------------------------- - -_--------- <br /> -- - <br /> ----- ----- ----------- -- - - --- <br /> Final Inspection by: �--- ------------------------------• ---------•--------------- ---------- <br /> -------------.Date --- --U- - - -- - . - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />{ E. H. 9 1-'68 Rev. 5M. <br />