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FOR OFFICE USE.- <br /> APPLICATION FOR SANITATION PERMIT // yy--�� <br /> --------------------------------------------------------- Permit No.7-5-�k1 x.13 <br /> (Complete in Triplicate] -- <br /> --------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued -------------------- <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> JOBADDRESS/LOCATION --- ------ ----------------------------------------------------------------------------------------------CENSUS TRACT -------------------------- <br /> Owner's Name -------- -------------------------------------------------------------- ------------Phone <br /> Address ---------- --------- --------------------------------------------------------------------- ------------ City ---------- ----------------------------------------------------------------- <br /> Contractor's Name --------------------•------------------------------------------------------------------.License # ------------------------- Phone --------------------------- - <br /> Installation will serve: Residence ❑ Apartment House❑ 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 ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ 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 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] . 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 /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---------------------------------- Date --------------------..---_--__----} <br /> SepticTank (Specify Requirements) ------------------------------------- --------------------------------------------I----------------------------------------------------------- <br /> Disposal <br /> --- ---------------------------------------------------------•----...-----------------------•-•------ <br /> Disposal Field (Specify Requirements) ------------- ---------------------------------------------------------- ------------------------------------------------------------ <br /> ------------------------------ -- ------------------- ----- ---------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and-required addition on reverse side) <br /> 1 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 /> --------------------------------------- <br /> By -------------------------- ----------------------------------------------------------------- Title <br /> ------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------- ---------------------------------------------------------- DATE ------------------------------------------- <br /> BUILDING PERMIT ISSUED ------------------------------------------- =-----------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS - - <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------- <br /> FinalInspection by- ------------------------------------------------------------ -------------.Date --------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M Sd <br /> - d <br /> Id <br />