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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .................•----............_...----............. <br /> 1Complete In Triplicate) Permit Na. <br /> ...................................I..................... <br /> This Permit Expires t Year from Date Issued Date Issued f Olq?A:Z( <br /> !-f I <br /> Application is h re y 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 <br /> h County Ordinance No. 549 and existing-Rules and Regulations: <br /> JOB ADDRESS/LOCATION .A .....s:>�::� " �f !�`"Y._ . .. <br /> TRACT <br /> CENSU5 .......................... <br /> Owner's Name —..A;......... - -----•--------•----------------------------�-------------.....----.......,-------Phone �_ .__....------•��=' <br /> Address S City <br /> -•--•-•------------------- -------------- <br /> _ .....-.,-. -c -__--•-, <br /> -----------------------------------------------License # _•_ phone _Contractor's Name <br /> Installation <br /> will.serve: Residence jJ Apartment House C] Commercial❑Traller Court ❑ <br /> Motel ❑Other........... -------------------- ------ - <br /> Number of living units ---- Number of bedrooms ..�......Garbage Grinder ...........- Lot Size ;.•_ <br /> ---------------- <br /> Water Supply: Public System and name ...............................-.............. <br /> A - _----------------- - - .. Private- _ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt o 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 t ] SEPTIC TANK I ] Size................................................ Liquid Depth ._.-----._...___ .......... <br /> Capacity ---------- ----- Type ............. ------ Material................•••... No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ---------------------- Prop. Line .................... <br /> LEACHING LINE ( j 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 /> . �.. Water Table Depth .........•......................................Rock Size -............................... <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ---------.---..-.---_.W <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) ............. -----------------...................,11.............. .................. <br /> .. <br /> ..... <br /> .:Disposal Field (Specify Requ' meats) 1 � �� - '"'�.. ? <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 lit accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Heine 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, 1 shall not employ any person In such manner <br /> as to become subjeFPIO Worm's Compensation laws of California." <br /> Signed -- --•--- Owner <br /> til -....----•-•--------�-------------- <br /> By -------------------•---- ----------•-------------- --------------------------------------------------- Title ---•- ---------- <br /> (lf other than owner) <br /> FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTER. BY . . ------------------ <br /> - --------= <br /> BUILDING PERMIT ISSUED ------------------------------ --- DATE .... <br /> ADDITIONAL COMMENTS .............................................. <br /> ------------------------------- - ..... --------------------- <br /> .--------------------------- <br /> .-----------------------------------------------....--------------•....................... <br /> --•----• -----------------------------•-----...._.. -------------•------. .----.Date ..d..� 9_. <br /> Final Inspection by. ` <br /> ' 24 lav• 5mSAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />