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-FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: <br /> ---------------------------------------------------------- <br /> . � <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> _ _ _ <br /> ---------- ---------------------------------------------- <br /> � h <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/LOCATION .-----. ._� _r�.� . J `R"s ------------------------------------CENSUS TRACT -------------- ..-.. <br /> Owner's Name }_._ Phone <br /> --- --- --- -- <br /> Address ------�-�-� �' ------------ City ----------------------------------------------••----- <br /> Contractor's Name -------- Ar-r�----sl ,_.License #1X,73,F�_ Phone ------------------------------ <br /> Installation will serve: Residence �Apartment House 1❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> -----------------------------------------Number of living units---------- ___ Number of bedrooms ------/----Garba_ge Grinder ____ ------- Lot Size ----- ___________ <br /> Water Supply: Public System and name ------------------------------------- ---------------------_-Private Id <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,) L <br /> PACKAGE TREATMENT f.] SEPTIC TANK'[ ] Size_ , __-!'_-1-_._1�___5----__._ Liquid Depth ----7__ _________________ <br /> r , <br /> Capacity II�Q_est-..- <br /> Type _ '�_ Material____ dC�___ No. Compartments _____ ........ <br /> Distance to neaWell _________JO__------------------Foundation _.__.l ___-_____ Prop. Line --. _____....... <br /> LEACHING LINE No. of Lines ________ __ <br /> C _____________ Length of each line-----------r!-A-d--------- Total Length -------�_�.Q-•----•_--- <br /> `D' Box y__ Type Filter Material -------g__'-___Depth Filter Material ------- `I'_`�___________________________ <br /> Distance to nearest: Well „rl--- _____ Foundation -------lP---------___ 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. Sanitation Permit# -------------------------------------------- Date --_-----------------------...._-_-) <br /> SepticTank (Specify Requirements) ------------------------------------ -------------------------------------------------------------------------, -------------------------- <br /> Dispos-al Field {Specify Requirements) --- _,__-___ _+ ------ ---- -�- _ . <br /> "- ---- ------ -------------------- <br /> 0 b <br /> --------------- ----------I------------------------------------ <br /> 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 /> "Itcertify 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' -ompensation laws of California." <br /> Signed ----------- ----- --- --- Owner <br /> gy ..e..{ ------------------------------- <br /> --- ----------- Title <br /> --- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> -------------------------------------------------- DATE ----42-_-��~�P- ------------ <br /> APPLICATION ACCEPTED BY __________ _`__.__- ___'________________________ <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------m--------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------- ----------------------------------------------------- ----------------------------- ------------- --------------------------- <br /> ----------------------------------------------=--------------------------- ---------------------------- -------------------------------------------------------------------------- ----------------------- <br /> - ----------------------------- ------------- --- ------------------ ------------------------------------- ----------- --------------------------------------------------------------------- <br /> --------- --------------------- ----- ------------ ----- ------ --------- -- ---------------------------------------------------- ------------------ -------•------- <br /> - -=-- ------------ <br /> Final Inspection by'. ------ `—may --- ------- - -------------------•------- -------------------------------Date 1*Z�--------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />