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I <br /> FOR OFFICE USE= APPLICATION FOR SANITATION PERMIT <br />....................................................... <br /> (Complato In Triplicate) Permit No. <br /> .............................................. <br /> -Dote Issued ..m�. <br />............................ ......... .................... This Permit lxplres I Year From Date Issued <br /> Application is hereby made to the Son 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 Regulotionst <br /> ..............CENSUS TRACT .................. .. .... <br /> JOB ADDRESS/LOCATION ........... . . . <br /> ....... .................... <br /> Owner's Name ................................. ................................Phone ......----...................I...... <br /> Address ....... city ........... ............... .............*...... <br /> ............*.......... <br /> Contractor's Name ..--••-----•-••-•- ...............License # ........................ Phone ............................... <br /> Installation will serve, Residence[9 Apartment House C3 Commercial oTraller Court 0 <br /> Motel 0 Other-------------------------------------------- <br /> Number of living units------------- Number of bedrooms. ............Garbage Grinder ............ Lot size ................................. .......... <br /> Water Supply. Public System and name ..............................................................7............................... ..........Private <br /> Character of soil to a depth of 3 feet. Sand E3 Slit[] Clay 0 Peat 0 Sandy Loom 0 Clay Loom 0 <br /> 4 <br /> Hardpan 0 Adobe 0 Fill Material ............If yet,type ............... ............ <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc.:must be placed an reverse side.) <br /> NEW INSTALLATIONS IN* septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK j I Size..r.............................................. Liquid Depth .......................... <br /> ... <br /> Capacity .................... Type .................... Material.......... --------- No. Compartments ............... ........ <br /> Distance to nearest: Well. ....................................Foundation---------------------- Prop. Line ...................... <br /> LEACHING LINE I No. of Lines ......................... Length of each line_-----,_._.___.__._._....... Total Length ........................... <br /> V Box ---------... Type Filtei'Material ....................Depth Filter Material. ............................................ <br /> Distance to nearest: Well <br /> ...................... Foundation ........................ Property Line .............. <br /> .... Rock Filled- Yes [3 No <br /> SEEPAGE PIT, Depth ..................... Diameter ................ Number ......................... <br /> Water Table Depth .........................-.....................Rock Size ........................!-....... <br /> Distance to nearest: Well ............... .........................Foundation ..................... Prop. tine ..........7.......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- ...................:...... Date ...................................1. <br /> SepticTank (Specify Requirements) ............................................:..................... .......................... ................... I.......................... <br /> Disposal Field (Specify Requirements) ....... . ..... <br /> .................................... ............... .......... ...........................................................................I.............................................. <br /> .................................... ........................... ........................ <br /> ...... .... .. .... .. .... ....... ..... .... <br /> ............................I............. I Draw existing and required addition on reverse side) <br /> 'I hereby certify that I have prepared this application and that the work will he done 16 accordance with Son joaqulw <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health' District. Homo owner or licenw <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 rkman's Cqmpeansat n laws of California."' <br /> Signed ....... jio,11�10 jW ...W.... . .... . ........................... Owner <br /> By ............--....................... ...... ........ .... .................... <br /> ....................... ............... ................... Title ............ 7 .......... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> E ........... <br /> APPLICATION ACCEPTED BY . . . .......................... ............................. DAT <br /> ........... <br /> BUILDING PERMIT ISSUED ................................ ------------------------------------- .................... ..............DATE ................................ <br /> ADDITIONALCOMMENTS .....................................................................................I----------I............ .........IL......... ........................... <br /> . . ......... ................... ...... ....... .............-........... ......................................... ................... .................L.�-------I............................. <br /> ...............1--"­"*...........- ............. . ..............*.................... <br /> ..... ...... .....i� --- --•------------------.... :........ ...............*........... ..L-1.......................... ... <br /> ............ <br /> ...................... <br /> Final Inspection by. ..........Date <br /> EH 13 24 1-68 Rev. 5�4 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />