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FOR OFFICE USE: 1!- ;r' <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- <br /> ------------------ (Complete(Complete in Triplicate) Permit No. <br /> J Date Issued <br /> This Permit Expires ] Year From 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 ADDRESS/LOCATIO -------- �.-f �------ -- -- ----------------------- -------CENSUS TRACT --•----------------------- <br /> Owner's Name ------------- ------- ----------------------------------- -------------------Phone� .^.----- <br /> Address d P __0 ---------------License #/ __--- Phone y- -------- <br /> Contractor's Name ------- <br /> Installation <br /> ..___Installation <br /> will serve: Residence Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- , <br /> Number of living units.-_/----- Number of bedrooms y._Garbage Grinder - -..�.Q: Lot Size -�a._..�1-................ <br /> Water Supply: Public System and name ------------------------------------------------------------- �� `t �-----------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan E] 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 ---------------------- V <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 iC, <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 /> Disposal Field (Specify Requirements) --------- <br /> 12-5 __._ 7- .c__. .____..___-..-_-___._ <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 /> "1 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 ---------4 -'- <br /> (If other owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- --------------------------------------------- <br /> --- --- -------------------------------- DATE �a .fid. .. ----------------- <br /> - - - <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------- --------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------- <br /> - ----- <br /> --------------------------------------------------------------- <br /> ---------------------------------- ------ ---- <br /> --- <br /> --- <br /> ------------ - --------- - -- - Date ....�� ------------------------ <br /> SAN <br /> � ------------ <br /> .. <br /> Final Inspection by: -- - - ----------------------------- - ---•-------------- -- - ------- . _ - -- <br /> ---- ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � }-� <br /> E. H. 9 1-'68 Rev. 5M " <br />