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* FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � <br /> i <br /> (Complete in Triplicate) Permit No. ..................... <br /> ............................................. This Permit Expires 1 Year From Daae Issued <br /> 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 Ordin ce No. 5a9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .. -. ., -----.-. . ..... ....... CENSUS TRACT ..............:.. .:.... <br /> Owner's Name .. .. .. ..... ..... ,....... ............Phone .................................... <br /> Address ........ .... City <br /> ........ ............. <br /> .:. <br /> Contractor's Name ....... .... • --- - -- .....G.'<.....................License # J ' .:._ Phone ........_ <br /> Installation will serve: Residence [Apartment House] Commercial ❑Trailer Court 0 <br /> Motel ❑Other ................. ........................... <br /> Number of riving units---------I--_ Number of bedrooms .....L...-.Garbage Grinder ............ Lot Size ..r^-=t r-. ... ........ <br /> Water Supply: Public System and name ---------•........................•----- -----•--•-••----------------••••••.._._............--•--------••••.....Private ©/ -4) , <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ ' Peat❑ Sandy Loam fA--___CIoy Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type --------------------------- 1 <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'[ j Size............................................... Liquid Depth .......................... <br /> Capacity .................... Type .................... Material............ --------- No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line _____................. <br /> LEACHING LINT: [ j No. of Lines ........................ Length of each line............................. Total Length .........................._. <br /> 'D' Boz ............ Type Filter Material ....................Depth Filter Material .................--•...................:.-. <br /> Distance to nearest: Well ........................ Foundation Property Lime .............._......... <br /> SEEPAGE PIT [ j Depth Diameter .......:...::.:. Number _....__..____............... Rock Filled Yes ❑ No <br /> Water Table Depth <br /> .. ......_.,___Rock Size <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ......................................•••••• Date .......... .................. <br /> Septic Tan <br /> t (Specify Requirements) .......... .................. ................ <br /> - ........................... ...................... ------------------ <br /> ----------------- <br /> Disposal Field {5 ecfY Requirements) <br /> L"^��*- *................ <br /> .....--••.......................................•--•-------------................ --------------------•-•---............................................ .............................................. <br /> i (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 ................................. Owner <br /> By ----•-•-------...._•......................... ,.. Title .. . ._.. . <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ......... .A. _.'...................•----•••--.......•••••................--•----......_....---• DATE ...P .. .............. <br /> BUILDING PERMIT ISSUED ...........=................... ---........--•-- --•---•--.................--•-•---_.......................DATE ............U...............I............. <br /> ADDITIONALCOMMENTS ---------•...................................•---------------•-•-----................_..•...-------•----------------_-_.--.-...---:..--• ..................... <br /> .........---••--•----•----•............................'........-:......---------------------------.................,------------------------ --------- ................ _.... <br /> 9 ............... <br /> Final Ins pection6y: ..__:---•---- ..Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E, 11 24 , c.. 7172 3,M <br />