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FOR OFFICE USE: FOR SANITATION PERMIT <br /> .............................:.................... ...... <br /> p9w Permit No. <br /> (Complete in Triplicate) .. ........ <br /> .......... ......... <br /> Date Issued .................... <br /> ..............................I................... This permit Expires I Year from Out*Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit-to construct and install the work herein <br /> described. This application is made in compliance with Countyrdinan Na. 549 and existing Rules and Regulations: <br /> P W <br /> JOB ADDRESS/LOCAVTO ........ ... . . . .................CENSUS CENSUS TRACT .................... <br /> ------- --------- ------- ...... .................... <br /> Owner's Name ------ e— .. .. .............. .......... ...Phone ..... <br /> 'Address <br /> . ... ....... ...... city .................... ....... <br /> Contractor's Name -- -- ----- .....License ..?. Phone <br /> Installation will serve.: Residence PLApartment House 0 Commercial ]Trailer Court 0 <br /> Motel 0 Other ....... <br /> .9... . ..... <br /> Number of living units:____._.___ Number of bedrooms ......Garbage Grinder ............ Lot Size <br /> Water Supply., Public System and name ..............................................................­­...........................................Priva <br /> Character of soil to a depth of 3 feet: Sand 0 Slit 0 Clay 0 Peat E] Sandy Loom 0 Clay Loom 0 <br /> Hardpan 0 Adobe 0 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 feetJI <br /> Size_....Lk ... Liquid Depth .... <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 1 4.................. <br /> _V---I-----I—— .............ti <br /> Capacity Type .................... Material.............. ....... No. Compartments <br /> Distance to nearest: Well ............ ...........Foundation ....... .............. Prop. Line .................0. 0 <br /> LEACHING LINE No. of Lines lk.........-. Length of each line----------7b7....... Total Length ..... ......... <br /> V -Box .-./------- Type Filter Material ......... Depth Filter Material ..../..T.............................. .I <br /> Distance to nearest: Well --------------_------- Foundation ......... .............. Property Line ............._........ <br /> SEEPAGE PIT Depth ._V�------------- Diameter 4../XvAvmber -------9. ................ Rock Filled Yes No <br /> Water Table Depth -----------------_---------I.........-•-•-••.. Rock Size ................................ <br /> Distance to nearest: Well ------------•------------Foundation• ............ Prop. Line .......... ----------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .....__....__-------------_--•) <br /> Septic <br /> ......... -_-------------_--- <br /> SepticTank (Specify Requirements) --------_-------11.............................................................................. ............I............................. <br /> DisposalField (Specify Requirements) ....... --------- ---------------------------_-- .............r............... ---------------- ---------------- ..................... <br /> ------------ ----------- -----------------------------------­---------------------------------------------------- ........­­---------- ............ <br /> ----­-----------------------------------1......... ..................I.................................................. <br /> ---------------------------------------------------------------------------- <br /> (Draw existing and required additiononreverse 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 Son 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 /> Ilf other than owner) <br /> FO 0EF!A_RTMV4T USE ONLY <br /> APPLICATION ACCEPTED BY ...... _J 0-VA .......... ------- ...... ...... DATE <br /> BUILDINGPERMIT ISSUED -------- --------- ...---•...-.............__...._:............--------........... ..............DATE ..................................... <br /> ADDITIONALCOMMENTS _—--- ----------- ..........................................................­­­....... ------ ....I....I............ <br /> ............ ................... --------------------------------------------------------------------------------------------------- --------­­­..................................................... <br /> ............. ............................................... ---------------...................................................­.........I....... .................­... ................. <br /> ----------- --------------------E)------------------------- ; .... ............................... ................ ........ ............­ <br /> ............... <br /> .... . .............. ..............Date <br /> Final Inspection by: --- ---- -- - -­ -------- <br /> EH 13 24 1-68 1 V SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />