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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT { <br /> -------------------- Permit No.z_fo <br /> (Complete In Triplicate) <br /> .......................................................... Dote Issued <br /> •.................................... I........... This Permit Expires I 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations- <br /> JOB ADDRESS/ CATIO p P.Z .-?�.. . .. .......................................CENSUS TRACT .................---...... <br /> Owner's Name .-- .. .. .. . . ......... ..- . .............. ...................................... .. ............Phone ..........1..................._..--- <br /> Address �. ,1. ---_..City ......._._. <br /> ............ ............ <br /> Contractor's Name License �# .�f,73,94-n-.. Phone .............................. <br /> Installation will serve: Residence Apartment Hous t] Commercial ❑Trailer Court 0j <br /> Motel ❑Other...... .... .... ........ ...•...- <br /> Number of living units:........... Number of bedrooms ............Garbage Grinder ............"Lot Siza ............ .. ..::..... <br /> Water Supply: Public System and nameP <br /> I <br /> ------------------------------- .. ....................... <br /> rivate <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay-loam [ ` <br /> Hardpan 0 Adobe 0 Fill Material . If yes,typo " <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 /> Capacity ....... ............ Type ••-•---------------- Material.........--•-......... No. Compartments ........ ......... <br /> Distance. to nearest: Well ....................................Foundation ........-:--.......... Prop. tine .....................6 <br /> LEACHING LINE [ ] No. of Lines ......-------------l.... Length of each line------------_--........... Total Length ............................� <br /> 'D' Box ---------- Type'1`16r Material ....................Depth .Filter Material ........................................... <br /> Distance to nearest.. Well `........--.............. Foundation .._..................... Property Line ........................ , <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ................ Number ._._.....-............------ Rock Filled Yes ❑ -.No <br /> Water Table Depth ....____.-.:-_--•----•- ..............Rock Size -------------------------------- <br /> Distance to nearest: Well ........................................Foundation .................... Prop. line ................. <br /> REPAIR/ADDITION lPrev. Sanitation Permit# --•-•--------------------------------------- Date ---------- ...-................) <br /> Septic Tank (Specify Requirements) ------------------------------------------4 •- -----------•------ .............................................-•........................ <br /> � <br /> Di ai Field (Specify Requirements) ...-.. <br /> ,r <br /> - -- ------- --- - - <br /> ya .5 <br /> . ---------- --------- •--••--- ••- ------ -----....-..-...-------------------------------------------.......-..........------...------,- <br /> 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 11cen- <br /> G sed : <br /> agents signature certifies the following- <br /> "I <br /> 9 9 g <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 ----------------------&nowner) <br /> --- Owner <br /> BY -- .. -- --= ---- Title - <br /> (lf othe <br /> -FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- DATE . .�. ...°Z-- ------ ------- <br /> --• •--- -------------- •---. <br /> BUILDING PERMIT ISSUED ---- ---------•--- -------------------------------- ----------- ....................DATE -... ........---_-----_-.__ <br /> ADDITIONALCOMMENTS ..........-----------------------------------------------------------------------------..............--•---------- - - • •---•-•--•----------------•----•-•-- <br /> k -------------•--"---------...------------------------------------------- -------------••----••---------------••--------------------------•---- ----- ----•..---•...----------------------•------------ <br /> ------------• --------------•----------•-•-- .-..--•--------•-----------------..-...-•---------....---•-----------------•-------- ............................................................ <br /> .. <br /> ------------------------------------- <br /> Final Inspection by: -- - _ --...Date - ' . .... <br /> EH 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> I <br /> I - l <br />