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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ -------------------------- Permit No: �__. <br /> (Complete in Triplicate) <br /> ---------=---------------------------------------------- <br /> This Permit Expires 1 Year From bate issued <br /> Date Issued <br /> _ _ _ <br /> --- ------------------------------------- <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 _1ZI ---------------CENSUS TRACT -----"---------_-.----d--- <br /> P <br /> hone <br /> � 4f <br /> Owner's Name city <br /> a� <br /> Contractor's Name -- - -- -- --- s ---- --- - ------ �- --- --�-'--------.License #vz_�_,__-'-�7�--- Phone -y <br /> ------------------ --------- <br /> Installation will serve: Residence gApartment House❑ Commercial:❑Trailer Court ;❑ <br /> '' // Motel F1 Other -------------------------------------------- <br /> Number of living u ts:_._�-____ Number of bedrooms _______Garbage Grinder ------------ Lot Size _ QQ__ _!�"'� ---------- <br /> Water Supply: Public.System and name _______________ _ _ ____ _--------._ -------------------------------------------------Private <br /> - - - - - ------------------------------------------------ <br /> ____ <br /> Character of soil toa depth of 3 feet j Sand'[] Silt 0 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 204 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] Size------------------------------------------ --- Liquid Depth ------------_---_--------- <br /> j i <br /> Capacity -.- ------ Type -------------------- Material---------------------- No. Compartments ---------------- <br /> Distance to'nearest: Well _______-__________________________Foundation -__-____________ Prop. Line ______--__:__-________ <br /> LEACHING LINE [ } No. of Lines-------------------------- Length of each line --------------------------- Tota) Length -_______-___-_----___-_. <br /> 'D' Box --------- Type Filter Material --------------------Depth Fitter Material ---------------------.---------------------- <br /> Distance tonearest: Well ____________________-__ Foundation ----_-.-__-_____________ Property Line ------------------------ <br /> SEEPAGE PIT [ ] Depth ----}_1------------ Diameter ___________ _ _ Rock Filled Yes 0 <br /> - --. Number --- ----------- © No <br /> WaterTable,Depth ------------------------------------------------Rock Size ------------------------------- �. <br /> r RS <br /> Distance to nearest: Well ----------------------------------------Foundation ------------ ---- Prop. Line -------------......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------••----------------.----'----) <br /> x . . . <br /> Septic Tank (Specify Requirements) --------------- ------------------------------------- `---: - x- - <br /> Disposal Field (Specify Requirements} © _'_ _ ----------- -- <br /> -+-------------------------- -------------------------------------------------------------------- ------------------------------------- ' <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 /> - <br /> I <br /> Sign ; ��i Owner <br /> I BY r --` Title(If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ___ ___ _ __-__- __ DATE ----- <br /> _. _ <br /> BUILDING PERMIT ISSUED ---------------------------------------------- -------- -------DATE <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------•------ ------------------------------ ------------- ----------------------------------------- <br /> f ----------------------------- -- <br /> ------------------------------------------------------------------ -------------------------------------- --------------- <br /> --------------------------- - - -- --------------------------------------------------------------------------------------- -------------------- <br /> ----------- <br /> ------------------------------------- ---- -- - -----------------------------------------------------------------------------------------D <br /> --------------------- <br /> Final Inspection by: ------------------- ------------------------------------------------.- ate <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />