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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ------------ <br /> -------- ---------- --------- --------------- --- (Complete in Triplicate) <br /> ---------=---------------------------------------------------------- Date Issued <br /> This Permit Expires 1 Year-From Date Issued <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 /> -- ---------•---- -- '` <br /> JOB ADDRESS/LOCATION _�tri -- <br /> -- " <br /> ---------------- ---- ---CENSUS TRACT -------------- ----------- <br /> Owner's Nome __ ---- --- ----------- ------------------ ------- -- -------- . ------------- <br /> ---.Phone ------------------------------------ <br /> Address ---------- <br /> Contractor's <br /> ------- ------------------------------------ <br /> ----------------------- City <br /> -- ---------------------------------------------------- <br /> a , / License # .� � � '"� Phone ------------------------------ <br /> Contractor's Name -.�� ----- - '''=- �'-�°-"""" <br /> Installation will serve: ResideIce partment House❑ Commercial ❑Trailer Court <br /> Motel ❑ Other ------------ -------- ---------------------- <br /> Number of living units:-----/..... Number of bedrooms _--3------Garbage Grinder ----------- Lot Size ____________________------------------------ <br /> Water Supply: Public System and name ------------------------------------------ ---------------------- Private El <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam E <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,I <br /> PACKAGE TREATMENT [ SEPTIC TANK:( ] Size-----------------------------------•-------- Liquid bepth __-----------------. <br /> Capacity -------------------- Type ------ -------- ---- Material---------------------- No. Compartments ------------• -------- <br /> Distance to nearest: Well --------------------------------------------Foundation ---------------------- Prop. Line --------------­------- <br /> ---------------------------- <br /> LEACHING <br /> --------- --------LEACHING LINE [ ] No. of Lines ------------------------ Length of each line.----------------------- Total Length <br /> T 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------A----------------------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------ ----------- <br /> k SEEPAGE PIT [ ] Depth ------------------- Diameter _-------------- Number ---------------------------- Rock Filled Yes No <br /> Water Table Depth ------------------- <br /> Rock Size -------------------------------- <br /> Distance to nearest: Well --------------------- ---;--------------Foundation -------------------- Prop. Line ----------------• --- <br /> - �-_ - ---- Date."_G ---------1 <br /> . /ADDITION(Prev. Sanitation Permit# ------- - --- <br /> Septic Tank (Specify Requirements) ------------- ------- ------------------ --------------------------------------------- -----------..__,,. <br /> Disposal Field (Specify Requirements) <br /> -------------- <br /> ----- <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 wilh Sass 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 /> - - - <br /> �' -1t-` " title ------------- - 4- 64- ---------- ---------------------- <br /> By ------ ---------------- ------------- ' <br /> (If other than owner) <br /> .FOR DEPARTMENT USE ONLY <br /> F APPLICATION ACCEPTED BY --------------------------- ---------------- - DATE _:�� .' <br /> f BUILDING PERMIT ISSUED -------------------------- DATE ...- <br /> ADDITIONALCOMMENTS --.-------- --------------------------------------------------------------- ------------------------------ --------------------------------------------------- <br /> _ _________________________________________________________________________________ _ <br /> __________________________________ ____ ________ _____________________________________ ____-.------ <br /> Final Inspection by: _;;:;?e-- <br /> --------.Dat ._.��.._ �----- --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. ' <br />