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FOR OFFICE USE: 1 <br /> APPLICATION FGR SANITATION PERMIT 4 <br /> -------------------------=----------------------------- <br /> D S` <br /> (Complete in Triplicate) Permit No ______________ ------- <br /> -------------------------- This Permit Expires I Year From Date Issued Date Issued <br /> App ion is hereby 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 County Ordinance No. 549 and existing RulesandRegulations: ; <br /> ,�•—�-�.,_---�.�.,��-«.�....-� - - - ------CEN RACT ------- <br /> --- <br /> JOB ADDRESS/LOCATION __. -_._ 4. K- <br /> Sys---- <br /> --- <br /> Owner's Name ------ --------- -- --------------------------------------------------------Phone <br /> Address ------------------------------------------------- ------.-. City ------------ <br /> Contractor's Name --------------------------- -----=-------.License # ---------:-------------- Phone ------------------------------ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial :F-]Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units------------- Number of bedrooms __.._Garbage Grinder ------------ Lot Size --------------------------------------------- <br /> - -------------------•--- <br /> Water Supply: Public System and name ____________________ -------------------------------------------------- ------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silty lay ,❑� 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 er it e septic tank or seepage p p g p permitted if public sewer is available within 200 feet,) � 4 <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ----- -------- <br /> Capacity -------------------- Type -----_------------- Material---------------------- No. Compartments - <br /> Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line --_---------:_.._.--- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ,__________-__------------- <br /> P <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 --------------------., <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ___________-_-____________________) <br /> Septic Tank (Specify Requirements) ----- - -- - - ---------- <br /> Disposal Feld (Specify Requirements) .________ - � <br /> -- ----- --- -------- - <br /> -- ----- <br /> 11 <br /> -- ---------- <br /> 1�- -------4---11011------- -- ----- -� <br /> -------------------------------------------------------.-------------- ------ ----------------------------=--------n-- .------------------=-- -- <br /> - - -� --(Draw existing rind 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 cerci 'es the following: <br /> "I certify that in the perfor ante of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to becomes bite to Wo Z�� <br /> ' pensati.on laws of California." <br /> Signed ------- -- ----- <br /> -- - ------------------ ---------------- Owner <br /> By ------------------------------- ---------------------------------------------- ------------------------ Title -------------- j <br /> (if other than owner) ! <br /> FO't .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -____. DATE ... <br /> BUILDING PERMIT ISSUED -DATE ------------ <br /> ADDITIONAL COMMENTS -------------------------------- -- --- <br /> ----------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- <br /> ---- ------------------------ 2 <br /> --------------- - - - - - - - - - -- <br /> ----------- - ------------------- - ------- --------- ------- ------ - - -- - <br /> Final Inspection by: ------ -.- - - - _ --- -------------------------------------------- ----------- Data <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �, I <br /> • w <br /> E. H. 9 1-'68 Rev. 5M <br />