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FOR OFFICE APPLICATION FOR SANITATION PERMIT <br /> ------ - --- ------. _ .�5� <br /> (Complete in Triplicate) Permit No. . <br /> -----_--_---_-_------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued - - -7.-/- <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 Count Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI N - -_ -_--' fl --,+-.�_------ ----CENSUS TRACT __'�__y�....._..____ <br /> Owner's Name -------------------------------------- --- - -Phone <br /> O O Q---I'2Z -0 2 <br /> Address ------------ --- ------ l 4� City ---- ----------------------------------------•------ <br /> r � � <br /> Contractor's Name -_______ -� __ _ _ d____ ------------ ---.--.License 2__._.License #� - Phone ---__________________ <br /> Installation will serve: Residence rApartment House,0 Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other --- ---------------------------------------- <br /> Number of living units:-----1---- Number of bedrooms __3---Garbage Grinder ------------ Lot Size _____________________________.__-________ <br /> Water Supply: Public System and name ----------------- -----------•----------------•----------------------.........--------------------------.-----Private IQ <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 /> (PI'ot 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 ___-______________-..._. rQ; <br /> 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 /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -------.____ <br /> -------------------------------- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ___----__._-_--__._.___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter --------I_____. Number ---------------------------- Rock Filled Yes ❑ No C <br /> Water Table Depth ---------------------------------• -------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------- Prop. Line ----------------.---_ <br /> REPAIR/ADDITION[Prev. Sanitation Permit# ____________________________________________ Date ______--____________-.____-.....__I <br /> Septic Tank (Specify Requirements) --------------------- ------------------------------ - ------------ -------------------------------------- - - -...- <br /> Disposal Field (Specify Requirements) _____ __ c>v+->-__ _________.___ f ____(, 'I - -y�---•-------- <br /> --- ---------------------------------------------------------- --------------- ----fir---------------------------•---•--------- <br /> �r© - -----'�-�----X� ---- <br /> (Draw existing and required dditiofi on "verse 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 /> By --------------- --------------------------------------- - Title ' <br /> ----------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT. USE ONLY <br /> APPLICATION ACCEPTED BY --�/� ----------------------------------------------------- ----- DATE —--------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------- -------------•--------------DATE <br /> ADDITIONAL COMMENTS -------------------------------------------------------------------------------- ------------------------------------- ------------------------ ---•----------- <br /> ----------- ---------------- ------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- <br /> ------------------------------- -- ----- - -- -------------------- <br /> Final Inspection by: ----------------------------------------------- ------Dater ---- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />