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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------- -- <br /> Permit No.. -65P-__7 <br /> (Complete in Triplicate) <br /> ----------------------------- --------------- <br /> --------------------------- ---I-------------------------- <br /> ----.............._-...-....._-__.-...-....-_._-.-..---....- This Permit Expires 1 Year From Date Issued <br /> 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 ADDRESSAOCAT O l�fru-, - ------- - ----------CENSUS TRACT -------------------------- <br /> Owner's Name - - - -- - -- - -- --------------------------- ------.Phone -------------------....------------- <br /> Address _.�. a ' - .z.+ --.,C. ® / Cit e ` <br /> k --------- ----------------- Y - -------------------------------------------------------- <br /> Contractor's Name --- .. ---------------------License # /Yef-3c]"-Phone <br /> Installation will serve: Residence pavement House,E] Commercial:❑Trailer Court i❑ <br /> Motel ❑ Other ------------ ------------------------------ <br /> Number of living units:------f_... Number of bedrooms ----/------Garbage Grinder ------------ Lot Size _._ -_____.__.....-... ---._.---_-- <br /> Water Supply: Public System and name ----------------------•-------------------------------------------•-------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam .0--" <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ---------------------.----- <br /> Capacity ------- Type -------------------- Material----------- ---------- .No.. Compartments •------ . <br /> r <br /> Distance to nearest: Well --------------------------- ".,_..FoundafiionY_Y".-; !,---__-. Prop. Line -------------:. __.... Ni,EACHING LINE [ ] No. of Lines ------------------------ Length of•each line---------------------------- Total Length ---------------------------- \' <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 ' <br /> Rock Size ----------------------------- <br /> F 6 <br /> Dista nce,to..n ea rest:.Wel I --------------- .-Foundation --------------- ---- Prop. Line ................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_) <br /> SepticTank(Specify Requirements) ---------------------------------------------------------------------------------- -----------------------------if------ ------------------••- <br /> Disposal Field (Specify Requirements) -------------------------------- --------------------------------- ---------------------- <br /> JP 440 pari 4 i <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: <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 _._ <br /> - - ------------------- Owner <br /> -- --- ------ ----- --------------- -- ------------ - --- -- <br /> BY ---- - --= --------------------- Title ------ is Ltl <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ._-- _ --------- -- -- DATE `��_ ' •- -------....-- <br /> BUILDG6PERMIT ISSUED --- --- ------------------------------------------------------ ------------------------------- --- --DATE --------------------------------------- <br /> ADDITIONAL COMMENTS <br /> --------- --- ----------------------------------------------------------------------------------------- ---------------------------------------- ----------------------------- <br /> ------------ <br /> ----------------------------------------------------------------------------------------------------------- --- - - <br /> -------------------------------- -- -- ------ <br /> -- - ------------------------------------------------------------------------ ------ <br /> Final Inspection by: =- .,' <br /> --------------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'S8 Rev. 5M <br />