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FOR OFFICE USE: <br /> APPLICATION FOR SANEIITION PERMIT <br /> ------------------------------------ <br /> (Complete in Triplicate) Permit No: <br /> - <br /> -------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued __��/` �-- <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. 349 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT - N _ -------- - ---- ---- 5 - CENSUS TRACT <br /> s, � <br /> Owner's Name ------ �/L .= ---- ---- - -`- Phone ------------------------------ ------ <br /> Address ----------AF_ - p Cit -------------------------------------------------------- <br /> Contractor's Name ......... <br /> �------� _ ''-License # .` <br /> ---'f= ----- -- -- -- ------- ------- - ------ Phone ------------------------------ � <br /> Installation will serve: Residence ' Apartment blouse❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> ! k, <br /> Number of living units--------!--- Number of bedrooms --- --- Grinder -------- Lot Size _._'---" - - ___.... { <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------------------------------------------------ Liquid Depth -------------------------- 6'\ <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 /> '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 0 <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 /> Di osal Field (Specify Requirements) „a4-- - ------ ,--_____-- <br /> ---- Q --- 4 ------- i---�---Z X ------ <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 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 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 mpensati.on laws of California.” <br /> Signed ---------------------- - ------------ Owner <br /> - ---------- - ------------- ---- ---- -- <br /> t <br /> BY - ------- ------------------------ <br /> --- - -------------- Title <br /> (If other than own( <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B -f -------------------------------------------------------------------- .a <br /> ------------- DATE ------------7------ <br /> ----------------- . <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------=--------------DATE --------------------------------------.. <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------- ----------------------------------------------------------------- ------ <br /> ------------------------------------------------------------4�� <br /> ------------------------------------------------------------------------------------------------------------------ <br /> - -------- -- ----- -------------- --------- -- --- - - - -- --- - ------------------------- ---. .------- ---- - - -- ---- --- ----Final Inspection by - --------------•--------- ----------------------------Date __ `!w��- ---- ---7 --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />