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FOROFFICE SE: APPLICATION FIR SANITATION PERMIT <br /> �"`w h Permit No: _ <br /> v <br /> �i/S.—LG \ (Complete in Triplicate) <br /> -------=---- �`" Ste___ �( <br /> _- `T This Permit Expires 1 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 . Q-. - ---------------------------------------CENSUS TRACT __ _ ............ <br /> Owner's Name .------ -------- -------- --------------------------------------_- -------Phone ----------------------------------- <br /> Address ? -- ------ <br /> City - - ----------------------------- -------------- <br /> Contractor's Name -------------- -----•-___-- ------_--_-------License # `CV-,571/------- Phone <br /> ------- ' <br /> Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---- ------ Number of bedrooms __.%__Garbage Grinder _---- Lot Size . x �L�------__---------- <br /> Water Supply: Public System and name ------- s° --------------••------------------------------------ --------------------Private ❑ <br /> Character of soil to a depth of 3 feet:' Sand' <br /> E] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Haidpan ❑ -.Adobe K. Fill Nlaterral�_- ,.If yes,type ----- - -- --- -- ---- - <br /> It . <br /> (Plot plan, showing size of lot, Igcation ,of system' in' relation to wells, bildPrigs, etc.•must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank oO seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT j ]' SLPI'IC TANK.[!] Size <br /> --- -------•------------ Liquid Depth ------ -------------.-•--- <br /> Capacity '- _--- --- -Type ----- ------------ Material-__ ------ ,---. No. Compartments <br /> Distance to nearest: Well: -----------------------_------------F,our-dation----------------------- Prop. Line -_•-______,_____--.-_- <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# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----------------- ------ ----- ----------- --- <br /> i <br /> Disposal Field (Specify Requirements) ------------------- -- ----- E U ---------- --------- ---------- ----- <br /> ------K-- <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 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 ---------- -- - ---------- ---- Owner <br /> BY ----------- -------- _ Title '-------------------- ------------------------------- <br /> --------------------------------- - <br /> (If other t a owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED - F - <br /> --- ----------------------------------------- --. DATE <br /> BUILD NG PERM TISSUEEDBY- -�--- ----- - -- -------DATE ---- ---------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------- ------------- -------- ------------------------------------------------------------------ ---------- <br /> - <br /> --------- <br /> -------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------- ----------- ----------------------------------- --------------------------------------------- ---------------------------- <br /> ----------------------------------------_rte-____ -- --_ -- -- -- ---- --------------- ---- _ <br /> Final Inspection by: ------- -- - - -----------Dpte --~�---� <br /> w` JOAQUI ' LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />