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-FOR OFFICE: USE: � <br /> APPLICATION FOR SANITATION PERMIT <br /> t-•.... ....... ................. Permit No. .................. <br /> (Complete in Triplicate) <br /> •.............................................. <br /> _ This Permit Expires 1 Year From Date Issued flats issued .. .3..._...... <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI„ N l° ✓.. ..... ....CENSUS TRACT <br /> Owner's Name ------�- - ...Phone .................. <br /> Address ......... 4f'---- . .... ... . . . . ....... .. . - -----.._.... City `........---...........--- .............I.......-.......... <br /> . � <br /> Contractor's Name ......... . .---. - --- - -- -- ---- -----------License # :eyf ..... Phone .............................. <br /> Installation will serve: Residen e [ Apartment House❑ Commercial:❑Traller Court 0 <br /> 1 Motel F1 Other --------- •-•---I........................... <br /> Number of living units:.....[____._ Number of bedroom�.......Garbage Grinder ............ Lot Size ... ........ ...... .....�. ._... <br /> Water Supply: Public System and name ................... . •------•------- ------------------------------------------------------- <br /> -------------------- ----------.--.----------------.Private L! <br /> Character of soil to a depth of 3 feet: Sand D Silt❑ Clay eat❑ Sandy Loam 0 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 240 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] Size................................................ Liquid Depth ..........................%Y <br /> Capacity . No. Com S <br /> P Y .................... Type -••----------------- Material........------------. Compartments -•-•--•------.......--.0 <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 /> Water Table Depth ...............Rock Size <br /> Distance to nearest- Well Foundation .................... Prop. Line ........_....._........ <br /> REPAIR/.ADDITION(Prey. Sanitation Permit# Date ...... ) <br /> Septic Tank (Specify Requirements) ......................................... - .........�....-••-•-•••---..w.........-........_..._.._..---•-••-• ----•-- ------ 0 <br /> Disposal Field (Specify Requirements) .. -- ----- -------- ---`-'`"' ..111"', <br /> � ..k_ / _X. .---------••-------------------------------------------•-•-•--......................... <br /> •..--._.....---------..I— ....--•- --------------------------------------------------------------------.----•--•-------.............--.------------.....---....._...__-...............--- ......... _ <br /> (Draw existing and required addition on reverse sidel <br /> 1 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. Horne 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 ....................................... 11_�.... . .. Title 1.. . <br /> ��' ... .................................... ......... <br /> (If other than owner) <br /> FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY ................... . ..l................................................._...................... DATE _..-- -. .. -G .. <br /> BUILDINGPERMIT ISSUED ....-•-••-----------•--------- -------------•------.....--••-•---..................-----------------------DATE ... ----•------- ................. <br /> ADDITIONALCOMMENTS .............................•----........--••---...--•---•---------------•-•--•- ................................................:........................... <br /> ..........................................................................................................._-._..........._._...__....-_.........-__-..._......_..._........._.__.........._..._... <br /> ...............................•--...----................. ....... <br /> ....._...-•------ •- --_. ....... � <br /> Final Inspection by: ................. ...............--•--------._...----•---...............Date ....__r� --- -- ............. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 13 24 W68 Rev. 5M 7/72 3 M <br />