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IiFOR OFFICE USE: f <br /> -------------------------------- ---------------•---- APPLICATION FOR SANITATION PERMIT f <br /> (Complete in Triplicate) Permit No. - - --5 <br /> -- - <br /> ----------------------- ------ -- ------------------- <br /> This Permit Expires 1 Year From bate Issued Date Issued <br /> r <br /> Application is hereby made to the S n Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in complia ce with County Ordinance No. 549 and existing Rules and Regulations: <br /> o <br /> JOB ADDRESS/LOCAT ON ------ ----�------ --- ----- - ------------------- ---- =- CENSUS TRACT ------------------ <br /> Owner's Name . Phone <br /> Address .-------- �-` ��--- City - ��1� -G' <br /> Contractor's Name ___ <br /> - ------�---•-=-�-----.License # -913V.� Phone ------------ <br /> Installation <br /> --- - - -•Installation will serve: Residence tApartment House❑ Commercial ❑Trailer Court !,❑ ° <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:-----1__-._ Number of bedrooms __----Garbage Grinder ------------ Lot Size _________________._-_ <br /> Water Supply: Public System and name - C '�{ ------------------------------------------------------ _-Private E]- ---------- ----- <br /> Character of soil to a depth of 3 feet: Sand'0 Silt❑ Clay ❑ Peat-E> Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑-- Fill Material ______1_._-_ 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 Depth --------------------------- <br /> Capacity ----------------- Type -------------------- Material----- --- ------ No. Compartments ---------------------- <br /> ------------------------------------< � ---------------------- ---------------------- <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 i❑ <br /> Wafter Table Depth -----------------------------------------:...--.Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line _-______--______.____. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ____--___-____-____.______________) <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------- -- <br /> y <br /> Disposal Field (Specify Requirements) ail�rlV----ra't-- ern -___, <br /> !x I =� ' - 4 <br /> 1: (k__ <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 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: I <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 ---------------------------- - q 'uTitfe --�`- _k--.cCee ['F -----...---------------------------------- <br /> (If other than owner) <br /> FOR DEPA1tTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -:---'--------------------------------- ) <br /> = DATE <br /> BUILDING PERMIT ISSUED -----------------------------------------------------------------------------------=------- -------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --'------------------ ------------------------------------- ---------------------------------------------------------------------------------- - ------ <br /> ------- ------ <br /> ---------------- -------------- - - ------------------------- <br /> ---------------------------------- -- -- --- - <br /> -- - - ---- ---------------------------------------- ----------------- ----- --- ------ ---- -------- <br /> Final Inspection by: ----------•----------------------------------------------------------Dat —--------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . ; E. H. 9 1-'68 Rev. 5M it <br /> - <br />