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FOR OFFICE USE: <br /> _ W APPLICATION FOR SANITATION PERMIT <br /> -- (Complete in Triplicate) Permit No. _7Z------------- <br /> O <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 /> JOB ADDRESS/LOCATION .__ L-f ___ _-____ _ ___________CENSUS TRACT ______________ <br /> `�� z f ... <br /> Owner's Name ------- -------=-/-� __ 8------` --------- ------ -------Phone �___---- t - <br /> --.... <br /> Address `` ------ -- ----------------------- ----------- City -- --------------------------- ----------------- <br /> Contractor's Name -_------ --- - . _ ____�:_______-License # _ 4 �______ Phone _ _:��_4a7_ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units:-_---r------ Number of bedrooms �.__.Garbage Grinder ------------ Lot Size _4�-- ---------------- <br /> Water <br /> _---- ®__Water Supply: Public System and name --------------------------------------------------------------------..--------------------------------.------.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ C+lay E] Peat❑ Sandy Loam E] Clay Loam El <br /> Hardpan ❑ Adobe:9 <br /> 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,) Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth .__________-_______-_. G'l <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------_--------- <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line -------------_------ <br /> LEACHING <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 i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------- ...... <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# Dfirate _ _______________________ _______) <br /> Septic Tank (Specify Requirements) _ .. ---- '"- "''`' <br /> �'��- x-�.- - _ --- <br /> Disposal Field (Specify Requirements) ___________ i <br /> ---- --- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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. 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------ - - -------- --------------------------------- Owner <br /> BY --------- -------- -- "----- ------------ ------------------------ Title ----------- -- <br /> (I other n owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- --- -- -- - --- --------------------------------------------------- DATE --- _ Z'--•--•-- <br /> BUILDING PERMIT ISSUED ---- - ------- --------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS -------------------------------------------------- --------------------------------------------------------------------------------=--------------------------- <br /> -------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ ------ <br /> ------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------- <br /> ----------------------------- ----- ---------- <br /> -------------------- <br /> Final Inspection by: -------------------------------------------------------------------------------------------Date - -----Cl' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />