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FOR OFFICE USE: w <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ <br /> - -- �4_.__7. <br /> (Complete in Triplicate) Permit No. _,7d-------------- <br /> --------=----------------------------------------------- <br /> Date Issued <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> � 3 ~ r --- ---------- ---- ----------------- ---CENSUS TRACT ----------------- -------- <br /> JOB ADDRESS/LOCATION O ' City <br /> sa ` <br /> Owner's Name ---------- ---- ---- ---- l ---- -- - ---------------------------------- Phone <br /> Address -------- ------- - <br /> ------- ----- <br /> Contractor's Name ----- _.License #0W_1Pr1'11*71 -____ <br /> Installation will serve: ResidenceXApartment House°❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of livingunits:--- ___-___ Number of be rooms ___ ---6F---- <br /> � ___,.Garbage Grinder�-�'___ Lot Size <br /> Water Supply: Public 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 [ ]PEIS)y_ �CSize------------------------------------------------ Liquid Depth ____--__---.______________ <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------------...__ M <br /> Distance to nearest: Well ------------------------------------Foundation _____.______________ Prop. Line -_________-________- La <br /> LEACHING LINE [V No. of Lines .___--- ---------------- Length of each line.------��---�- Total Length �_--------------.. <br /> r Ul <br /> --____-- _.! <br /> 'D' Box ---e---- Type Filter Material _ _____Depth Filter Material __,�, _r <br /> Distance to nearest: Well `'' ___ Foundation _ �---___________ Property Line ____ ........ <br /> SEEPAGE PIT JV Depth + - Diameter .3.2_11--___ Number ____l________________ Rock Filled Yes f4i No (:3 <br /> Water Table Depth --- Q-l---------------------------------Rock Size --- ._�� <br /> ------------ - <br /> Distance to nearest: Well ..........Foundation -------- Prop. Line ---- --'------r-- <br /> ------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------.------_----------------------------- Date ________________________________-_j <br /> Septic Tank (Specify Requirements) ------------------ ------ --- ---------------------------------- ----------------------------------------------- <br /> 0 <br /> Disposal Field {Specify Require -eats] ---- r <br /> -------- -- --¢---- <br /> ----------- „.,. _---------��-------------- ' ° cu%' <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, 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 /> ----------------------- - <br /> BY - own' - --- ---- ---------------- Title -------- <br /> ---- ------------ -- - ------------------------------ <br /> (I of er t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE �` '------------------ <br /> BUILDING PERMIT ISSUED --------------- ----------------------------- -------- DATE ------------------------------------------ <br /> ------------------------------- -- <br /> ADDITIONAL COMMENTS -- ------------- -------------------------------------------------------------------------------------------------- <br /> ----------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------- <br /> ------- -------- ---- <br /> - ----=------------------------------------------------------------------------- -- ------------- - ---- <br /> Final Inspection by: -- -N- Date -- �--- - ___--�------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M SCJ <br />