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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. <br /> (Complete ..:.b S� <br /> This Permit Expires 1 Year From Date Issued Date Issued .................... <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/LOCATION ...��.. .��..�...... fE: ...... ....' /� cL'. . .......... ... .............CENSUS TRACT .............. ....---.... <br /> Owner's Name .............¢.... �� >" <br /> �.:..�...... ..........tj:................................. ,................. ..............Phone .................................... <br /> Address ..._.................. ... '...... +- 3..ei....... ....................... City s :.....-... <br /> .................... <br /> Contractor's Name ...... License # Phone .............................. <br /> Installation will serve: Residence ❑Apartment House Commercial ❑Trailer Court 0 <br /> Motel ❑Other ....... <br /> ------ ------.•--•--••--•---- <br /> Number of living units Number of bedrooms ..--.-Garbage Grinder ...... Lot Size ...... ............... <br /> Water Supply: Public System and name .............................................................................................................Private [ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam [?r 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-fe Size. ��. �t..c1. . .. X 5'. .. Liquid Depth ...... ...... <br /> Capacity .......... Type Material.... No. Compartments ..c . ............... <br /> Distance to nearest. Well ....... --.--.---.-Foundation ......1..G..l-et Prop. Line ...,�' ....... <br /> LEACHING LINE No. of lines .........1............. Length of each 114, .. Total length ....`-1z.1.,.(........ <br /> 'D' Box ............ Type Filter Material ....... .- ...Depth Filter Material .-.....-/..11.............................. <br /> Distance to nearest; Well ......t.G .. t. Foundation ....jam. ...... Property Line ...5. :....... <br /> SEEPAGE PIT (4Depth .._. .S Diameter .�'�. .:`.... Number .............. Rock Filled Yes [ No Q <br /> Water Table Depth ...............ff.°.TU.../.................Rock Size .. <br /> Distance to nearest: Well .......... -`------------Foundation .1.-S?------ Prop. Line .... '. <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ..........................................._ Date ..................................) <br /> SepticTank (Specify Requirements) ........-................................................................. ..•-----.-----.-----.•-...-.-.•--............_......--•---..... <br /> DisposalField (Specify Requirements) ..................................................................................................................................... <br /> ....--•--•-•-•--•.........-•...............................................••----- -••••--• .......................................................................- --•--•---••......................... <br /> .......•.............................................----•.-.-.................--•--.----•----••-•-•----•----..... .................................. ............. ........... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licwo. <br /> sed agents signature certifies the following: <br /> "1 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 ._. ............... ................. ..... ..----.. Title ...... <br /> ` ........................................ <br /> (If other than owner) <br /> _FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... ............................. DATE .�j�.'..��Z.. ..-.................. <br /> ...... .... .............................. <br /> BUILDING PERMIT ISSUED ...---------•-•.................................................................••--•-...............---..DATE ......---•--....---............ ........... <br /> ADDITIONALCOMMENTS ..............•--....................................•...---•--..._.....................................................----...........................••---•• <br /> ................ ................. ....................................•--.................................................................................................................. <br /> .......... ,.:.......................... ........................................................................................................... <br /> ................................ <br /> FinalInspection by: ---- .........................................................................Date .i... /........................ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241-'68 Rev. 5M 7/72 3 M <br />