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FOR OFFICE USE: <br /> VPLICATION FOR SANITATION PERMIT <br /> --------------- ------. Permit No. _4�_ a J <br /> (Complete in Triplicate) <br /> ------------ - ------------------------- <br /> ,,. This Permit Expires 1 Year From Data Issued d - � <br /> Date Issue -' � � <br /> ----- -- ----------- _--- -------------- ------------- <br /> _ _ -- <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 Co my Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT N 2-� 7-- CENSUS TRACT _ <br /> Owner's Name --------- ----- _ •-------------------Phone ------------------------------ <br /> Address _- d" �� City :_ --- - <br /> y <br /> Contractor's Name --- - License # Phoned •-- <br /> Installafiion will serve: Residence ❑ Apartment HousexCommercial :❑Trailer Court ',❑ <br /> Motel ❑Other -------- ----------------------------------- <br /> Number <br /> ---- ----------------------------Number of living units:_.__ Number of bedrooms --�-Garbage Grinder -_-_�'-- tot Size <br /> Water Supply: Public System and name 0Q!��4�4------------- -------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet,: Sand'❑ Silt F1Clay E] Peat ElSandy Loam ❑ Clay Loam;❑ <br /> k <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 ____.______---_--------- <br /> r <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 /> ___.__ <br /> ________Depth Filter Material <br /> 'D' Boz -----'--- --- Type Filter Material -------------------- -------------------------------- ----- <br /> ��- -- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ---------.-_-_-___---_ <br /> SEEPAGE PIT [ ] Depth ----- ------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth -----------------------------------------------Rock Size --------------------------------- <br /> Distance to.'nearest: Well ----------------------------------------Foundation -- ----------------- Prop. Line -----------•--------_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------- - Date ---------._-----------------------) <br /> SepticTank (Specify Requirements) ----------------- ---------------------------------------------- ------ ----------------------------- ---------------------------- <br /> . <br /> --------------------------- <br /> ibisposal Field (Sp ' Requrements) ____ --- ----------- <br /> ------------ --------------- <br /> /./ <br /> --------- ----- = :- ------------------------------------------------------------------ - <br /> :1 <br /> ------------ ---------------------------------'-------------------- - <br /> I(Drawexisting.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, 1 shall not employ any person in such manner <br /> as to becom ct t ,WorkmaCompensation sof California." <br /> Signe � eic-.Gf Owner <br /> BY ---------- -- ------------------- --- --- ------------------------------------------------------------ Title .............. <br /> -------- -- .................................................... <br /> ---------------------------- ---- --------- r <br /> (If other than owner) i <br /> od FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - _. -------------------- DATE _ a�-- - - <br /> BUILDING PERMIT ISSUED --------- 'i J DATE -- ------------------------------------- <br /> ADDITIONAL COMMENTS . -' — >*' �� L"" ----------------------- ------------------- --= + <br /> ------------- --------------------- --------- --------- ------------------------------------------------------ �- ------------------------- <br /> ---------------- <br /> - ----------- ------------------------------------------------ ---- - ---p�---------------------------------------------- <br /> ----------------------------------- <br /> - ----------------- ------------- -------- <br /> Final Inspection by. <br /> ---- ------- ------Date i <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M d <br />