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FOR OFFICE USE: : <br /> APPLICATION FOR SANITATION PERMIT �� v <br /> ------- <br /> -- --------------------------------- <br /> (Complete in Triplicate) Permit No: . ._-__-=f---..._-. <br /> - - Rate Issued <br /> ---------------------------------------------------------- .. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein a <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> Y - <br /> JOB ADDRESS/LOCATION <br /> _�z- <br /> -------• ----- ----------- -----CENSUS TRACT --------------•----------- <br /> Owner's Name ----. -------------------Phone------- ----------------------------- <br /> , <br /> 3 ------------------ LP----- ------------------- ------- -------------- City - <br /> ------------------------------------------------------------ <br /> Contractor's Name --------------------•<Wlhl4�---------------------------------- ------.License # -- 7 - Phone <br /> Installation will serve: Residence [k<partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- n/ <br /> Number of living units:----/ Number of bedrooms ___3-----Garbage Grinder -.�-�- Lot Size4�0i -'------------------ <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:[ Size----------1-0�-�J'-t--.------------- Liquid Depth -_� 2------------- <br /> Capacity -1 Type _ t ..-- Material__C(AC�eA­._ No. Compartments ----- ---- <br /> Distance to nearest: Weil ____ -�_____________________Foundation -A ------------- Prop. Line <br /> LEACHING LINE [ ] No. of Lines __q...... Length of each line----- a--------------_ Total Length :_--------- <br /> � � rr <br /> (L ,,`( 'D' Box .1e,5.---- Type Filter Material __SV_ _---Depth Filter Material --------1_<K----------------------------- <br /> p k,---------- Foundation Property Line. ---- <br /> Distance to nearest: Well ___- ___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No Cl <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) -------------------------------------------------------------------------------------------- -----------------•----------------------------- w <br /> DispoI Fi I cify Requirements) --------------------------------- ------ ------------------------------------------------------ ------------------------------------- L� <br /> -- ----- --- - - ---------------------- ------------------------ <br /> ----------------------------------- --------------------------------------------------------I------------- ---------- <br /> ---------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I ha a 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. Hoene 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 /> BY ---------------------------------------------------------------------- ------ --------------- Title ------------------------------ --------------------- ------------------- <br /> (if other than owner[ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------- ------------- ----------------------- ---- ---------. DATE --- F- �--- ---------- <br /> -BUILDING PERMIT ISSUED ------------------------------- ----------- ------------ -- -------DATE ------------- ------ <br /> ADDITIONAL COMMENTS ------------ --- - - - ------------------------ -------- --------------------------------- --------------------- ---------------------------------- <br /> ---------- - --------------- -- ------------------------- --------------------- <br /> ---------- ----------- <br /> Final Inspection b ---------------------------------------- - -----------.Date --------�1 -------------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />