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= FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> t Expires 1 Year From Date Issued Date Issued <br /> (Complete in Triplicate) Permit No_ _____________________ <br /> 4 <br /> ________________________________________________________ This Permi <br /> Application 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 Rules and Regulations: <br /> JOB ADDRESS/LOC T % -------�.-- -----------------7---------------------------CENSUS TRACT .......................... <br /> Owner's gZe ...... ---- - - -- - - ---------- <br /> - <br /> .............Phone •..... <br /> Address -4.3-4 .. -- ---A --------. <br /> City --- <br /> ---- ---------------------------------------------- <br /> Contractor's Name ---C;;: _._S_ --_� ______________________License # Phone .............................. <br /> Installation will serve: Residence ft Apartment House❑ Commercial QTrailer Court ;❑ <br /> Motel ❑Other ----------------- .......................... <br /> Number of living units:-----.----- Number of bedrooms .y...Garbage Grinder _----------- Lot Size ----- --------------�.�._. <br /> Water Supply: Public System and name -----------------------------------•----•------- ---- PrivateA <br /> Character of soil to a depth of 3 feet: Sand'Q Silt❑ Clay ❑ Peat Q Sandy Loam Clay Loam 'Q <br /> Hardpan ❑ Adobe'Q 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 .................... <br /> Capacity -------------------- Type .................... Material---- ----------------- No. Compartments ...................... W <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 ........................ �'f1 <br /> SEEPAGE PIT [ ) Depth -------------- Diameter ................ Number ---------------------------- Rock Filled Yes ❑ No C <br /> Water Table Depth ------------------------------------------------Rock Size ................................ X <br /> Distance to nearest: Well ________________________________________Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------.......... Date ____________________--____---_---_) <br /> SepticTank (Specify Requirements) ---- ----------------------------------..----------R------------------------------ ---------------------- ----- •------------- ........ <br /> Disposal Field (Specify Requirements) _._.� --eccj.-- __-_-- --^-- - <br /> -------------- *^K <br /> 1 Q -- - ------------------------------------ ------------ ----I--------------------------------------- <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 Compensation laws of California." <br /> Signed _.---------------- <br /> - Owner <br /> Ti <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- -- ---- ------ ------------------------------------------------------- DATE <br /> BUILDINGPERMIT ISSUED ------------------------- --------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------- ----------------- ---------------------------------------------------------- ------ ---•---------------• <br /> ________________________________________________________ -----------y-------------.------------------------------------------------------------------------------_._-___-.________-_-_.----__----....._ <br /> ______________________________________ __ _ ------------------------------------------------------ -----------_____--f <br /> --------------- <br /> Final Inspection by: ____ __ ______ _____ __________ -__ _ .._Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F H 9 1-'hR Rav 5M <br />