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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. . ---------- <br /> (Complete in Triplicate) <br /> - <br /> ------------------------ Date Issued <br /> - <br /> -------------------------------------------------------- This Permit Expires 1 Year From 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 <br /> made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION/6_7 ____ ______________ .r!>0/----------- <br /> CENSUS TRACT -------------------------- <br /> Owner's Name ------ , <br /> Phone a2 <br /> Address --------- _------ ------------------------------ ------------ City _------------------------"----�--?--�----�--- <br /> •-- <br /> Contractor's Name ____/� �___________---___________--------License # " Phone . ✓`, _ <br /> Installation will servo: Residence ❑Apartment House( Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- 1, "Q C <br /> Number of living units:---._-__ Number of bedrooms 4-------Garbage Grinder ------------ Lot Size ----7_------ ............ <br /> Water Supply: Public System and name ------------------•- --------•-----------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ 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 pylic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth .......................... <br /> Capacity -------------------- Type -------------------- Material-------------- ------- No. Compartments ---------------•--- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----____-- ........ %3 <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 iC <br /> Water Table Depth -------------------------------------- -------Rock Size -------------------------------- T to nearest: Well -----.----------------------------------Foundation -------------------- Prop. Line ....____...._......... . <br /> REPAIR/ DDITION(Prev. Sanitation Permit# ________________________________ Date ---------------------------------- <br /> ticTank (Specify Requirements) --------------------�-;-------------•-------------------------•------------------------,------------------� ---------------------------- <br /> Disposal Field (Specify Requirements) --------l-'__1 Z�__-____- -_--------��---11X/T---____________________ <br /> - -------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - ----------------- --- ---- -- ---- - - - -- ---------- ------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 subj to orkm 's Compensation laws of California." <br /> Signed --- k -- --------- ---------------------------------------- Owner <br /> By ---------------------------=----------------------------------------------------------------------- --- Title _ .------------------- ------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - -- ----------------------------------------------------------------_-----------. DATE -----10-�-~ <br /> BUILDING PERMIT ISSUED:__ _.. - _____________DATE ---------------------- --. <br /> ADDITIONALCOMMENTS ---- -------------- ------ --------•--------------------- -------- ------------------------------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- - - <br /> ------------------------------- -- - - <br /> Final Inspection by: Date ------- - <br /> SAN JOAQ UIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />