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FOR OFFICE: USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------------- ---- <br /> {Complete in Triplicate} Permit No. <br /> ---------------------------------------------------------- <br /> --------------------- This Permit Expires 1 Year From Date Issued Date Issued --.- -`-r` -7 <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/LOCAT ��_____C ---- - -- -- - --- - ----- -�`_ CENSUS TRACT _s-. /�-...-......_. <br /> - ----- ------------------------------- <br /> Owner's Name la`s - -----•------------ Phone <br /> - <br /> Address -------- '+'---- - ------------------------- ------ City -----------------------------------------------------------_ <br /> Name .- <br /> ----- ----- ----------- �--,�--- --- ---- ----------.License Phone <br /> Installation will serve: Resident ❑ Apartment House,0 Commercial ❑Trailer Court !❑ <br /> Motel ❑ Other -------- ------- - <br /> Number of living of bedrooms ----------.- tot 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 seep a pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![,f Size--V1_Z-�� - ___�___ Liquid Depth ----- ------.-.._--_- <br /> Capacity - �"'�'- Typed-.- Material45, '�--_____ No. Compartments -- <br /> No. <br /> Distance to nearest: Well _______-____ <br /> .5d,--------------------Foundation -- /_a---------- Prop. Line --------------- �`�... <br /> LEACHING LINE No. of Lines ___________f------------ Length of each line--------------------- ------ Total Length __72._Q_./-------------- - <br /> 'D' Box ------- --- Type Filter Material -----S-12-------Depth Filter Material -----.I:q-- ----------------------------- <br /> ° jn <br /> Distance to nearest: Well ___-- SA........... -----1 ---------- Property Line ----C Foundation <br /> itz;IM-1 [ ] Depth -------P11r--------- N-ameter -2_---kP_- Number -----------------_-------- Rock Filled Yes E5/ No <br /> Water Table Depth ----------.:-------------------------------------Rock Size ---------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -_--------------- <br /> REPAIR/ADDITION <br /> _-_--.._-_-_- _-REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---------------------- ----------------------------------------------------------------------------- ------------------------- <br /> Disposal Field (Specify Requirements) _--.--_-__- -__-___-_---_-.------____________________________-r <br /> --- --------------------- ----------- -------------------------------------------------------------- ---------- ------------------------------------------ ------ <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 pensation laws of California." <br /> Signed - - - Owner <br /> �� Title . <br /> --- ----------- <br /> BY ' <br /> (If other than owner) <br /> df FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ - -- ---------------- -------------------------------------------------------- DATE J'__-!�/_-2--------- <br /> ---------- <br /> BUILDING PERMIT ISSUED -------------------- ------------------------------------- <br /> ------------------------------------------ -----DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS --- ---------------------------------------------------------------------------------------- ---------------------------------------------------------------- <br /> --------- ------------- ----------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- -- ----- - <br /> --------- ------------- ---------------------- -- - �- -- - -------------- <br /> ----------- <br /> - - - - ------------------ <br /> Final Inspection b __Date _._, . `' --------------------- <br /> ------------------------ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M �� <br />