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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. -- �__- --�---. <br /> ---------- ---------- --------------------------- <br /> This Permit Expires 1-Year From Date Issued Date Issued <br /> Application is herebyade to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in complia�ounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB iADDRESS/LOC ?N . jJ�I - -- -- -----�------------------------------------ ------ CENSUS TRACT <br /> Owner's Name C.� _ '' -��- i'`- - ------------Phone -------------------- •----- <br /> Address / / , ----- ---------- ---------- City 6S-F� « <br /> ra � <br /> Phone -------------------------- •- <br /> Contract9r,,s Name = � <br /> .4 w. <br /> Installation vill serve: Residence Apartment House�❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---J----- Number of bedrooms ---J-----Garbage Grinder ------------ Lot Size ----- --_-----.-.. <br /> Water Supply: Public System and name ---------------------------------------------------------- --------------------------------------------------Private 2 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt ❑ Clay 2� Peat❑ Sandy Loom ,E] Clay Loam]] <br /> Hardpan ❑ Adobe ❑. Fill Material .---- --_:If yes,type ---------------------------- <br /> (Plot-plan, <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-[ ] Size------------------------------------------- ---- Liquid Depth ---------------------.----- <br /> ns Capacity -------------------- Type -------------------- Material--------- "----------- No. Compartments ------ --------------- <br /> Distance to nearest: Well ------------------------------------Foundation ----------------------- Prop. Line-------------_------ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line----------__---------------- Total Length --.----._ <br /> --------------- <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.(Prev. Sanitation Permit# -------------------------------------------- Date ...-.--.------.-_--.--..-.--_-.-) <br /> Septic Tank (Specify Requirements) -------- ------------------------------- - ----------- ------------------------------ <br /> -------------- - ----- --------- . <br /> Disposal Field (Specify Requirements) ----- - , r---- - r. <br /> --X 5 - � ------- ----------------------------------- <br /> h <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: a <br /> "Icertify 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 --- ---------- �r �ti%Yc ..'a !s1 yt.}6�,1. Title --- W------. ----- ------- <br /> (If other than owner) f- <br /> r wF <br /> FOR .DEPARTMENT USE"ONLY <br /> APPLICATION ACCEPTED BY ..._____... DATE __- --- -- - <br /> ------------------------------------= <br /> BUILDING PERMIT ISSUED ----------------------------- -------DATE ----------------------_. <br /> -------------------------------------------------------------- ------------------- <br /> ADDITIONALCOMMENTS ----------- --------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------- <br /> - -------------r--------------------- ----- <br /> - --------- <br /> - -- --- - <br /> ------------------------------------------------------------------------------------ - - <br /> Final Inspection.by: --...Date "� �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E H. 9 1-'b8 Rev. 5M `• <br />