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r FOR OFFICE USE: <br /> — — - _. <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. ...,................. <br /> ....... This Permit Expires I Year From Date Issued Date Issued ..................... <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrLict 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/LOCATI N _6. ol,$W..___.•.jr , -�/.J� <br /> :..............................CENSUS TRACT <br /> ..................... <br /> Owner's Name ._... -•-- <br /> .............�_��.7 _.. ..._-.-.-.. - --- ..-• --..-- .................. `._........Phone <br /> Address <br /> -- - --------- <br /> ----- City�;� <br /> :.Contractor's Name ... _ _.._.. ..... <br /> ..................•-•-- <br /> ....... ............__License # /. .S,�.�--.. Phone <br /> Installation will serve: Residence Apartment Housefl Commercial❑Trailer Court <br /> Motel ❑Other ...........- <br /> Number of living units:-..--- Number of bedrooms .---.' --Garbage Grinder ............ Lot Size <br /> Water Supply: Public System and name .............. Private Q� <br /> Character of soil to a depth of 3 feet: Sand❑ Silt:❑ Clay ❑ Peat❑ Sandy Loam er"',Clay Loam <br /> Hardpan ❑ Adobe fl 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 f ] SEPTIC TANK ] Size................................................ <br /> 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.----------......_.._....__. Tota! Length <br /> ......................... <br /> 'D' Box ..__.._ .... Type Filter Material ....................Depth .Filter Material _ <br /> Distance to nearest: Well ....----------_------- Foundation _._..._.. ............. Property Line <br /> SEEPAGE PIT O Depth --._.----- ------ Diameter ................ Number ------ ...................... Rock Filled Yes ❑ No >❑ <br /> Water Table Depth ------------------------------------------------Rock Size ............. .................. <br /> G <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------- -------- Date ._._....__._•..-- ) <br /> Septic Tank (Specify Requirements) --_--------------__ <br /> --------__-• <br /> -•--- ----------------------------- -------- <br /> Disposal Field (Specify Require ents) z�.a�--- <br /> ' !q, <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 /> Signed ---------- ------------•- Owner <br /> BY �.------- --------------- Title <br /> ._ �?s.J. ar' <br /> ------ ------- --- --•------- <br /> (if other than owner} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... --- _ -:-.7. <br /> DATI? , .....:,_. _-� ._ -.._----- <br /> BUILDING PERMIT ISSUED -.. ------•-•-------------•--------------- ----------•--- -------- ---------•..............-- - ------DATE ....... ­-------------------- <br /> ADDITIONAL COMMENTS -._-•....-...----------------------------------------------- <br /> -------- --------------------------- ................. ....... <br /> --------------------------------------------.._..------..----------------------------------------------.-------------------------------------- ---............. <br /> ..._.. . .._ <br /> --------------------------------I............. <br /> fir- - - ..............•------•.._.,...--•--------------- -•------------•-----�...-..... _ ._._.,-•---....... <br /> Final Inspection by- --------------- - c ' -- <br /> .............. ...................................................-......Date ......... 7J ............... <br /> EH 13 24 1-68 Rev. Sm SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />