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FOR OFFICE USE: <br /> e� APPLICATION FOR SANITATION PERMIT <br /> ------ `----------------- (Com Permit No. <br /> . fete in Triplicate)p p <br /> This Permit Expires ] Year From Date Issued Date Issued <br /> --------------------------------------------------------- f , <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 LOCAT ON ` f_. � ✓ t�_ -_-._CENSUS TRACT -------------------------- <br /> -------- <br /> I <br /> Owner's Name r -__ -Phone ------------------------------------ <br /> ------------ ' <br /> Address (°/jj l `` _ City / ` -----------------------------------•------ <br /> i7 --- -- -- f� ? <br /> Contractor's Name __ _ _/ i fr, k. <br /> --__-_-`1__________ '---_License #p �-a,�`c !_ Phone� � .. <br /> Installation will serve: ResidenceX Apartment House❑ Comm6rcial ❑Trailer Court i❑ 4 �J <br /> Motel ❑Other ---------------- ------------------�!--- <br /> Number of living units:__------ Number of bedrooms __.T---__Garbage Grinder . --- Lot Size��i�' , <br /> ----------- <br /> - --_-_ -------- <br /> Character <br /> PrivateWater SuPPIY Public System and name --- <br /> Character <br /> ❑ <br /> of soil to a depth of 3 feet: Sand'o Sift❑ Clay ❑ '*Peat❑. .- Sandy Loam -❑ Clay Loam <br /> Hardpan ❑ Adobe J� Fill Material ----.-- __ If yes,type ____________________ <br /> . �f <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. Line -_---__---____-__-__-- <br /> LEACHING 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 <br /> Water Table Depth ------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ________________ Prop. Line _---__---__-___--__-_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------- --`---- -------- -------- <br /> Disposal Field (Specify Requirements) _ / ______________ <br /> --------- ------ - <br /> ----------------- r ------------------------ <br /> ----- -- ---- -- --- <br /> rdw e�cisti g drfd reciu re d iti on rev rse side} <br /> I hereby certify that I have prepared this application and that the work will be done n 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 d� <br /> --- <br /> (I other than owner) <br /> MENT USE ONLY F <br /> APPLICATION ACCEPTED BY ---- - = -- -------- ---- -- -- -- ------- ---------------------------- -------------- DATE ` �----•- <br /> BUILDING PERMIT ISSUED ------ --- --- -- -- --- - ------------- ---------------------------------------------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS <br /> ---------- -------------------- - ------ -- ----------- -------------------------- --------------------------------------------- ---------------------------------------- <br /> - -- - ------------------------- <br /> -- -------- -- ---- ----- ---- -------------------------------------------------------------------------------------------- -------- <br /> Final Inspection by: - . - <br /> -------------------------------------------- -----_ / �----•------- <br /> S JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5 <br />