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FOR OFFICE USE- <br /> --------------------------------------------------------- <br /> SE: APPLICATION FOR SANITATION PERMIT <br /> ------------ - --- -- --------------------------- Permit No. - --�--�' <br /> (Complete in Triplicate) / <br /> ---------=-------------------------------------------- <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 per 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 .- �_ CENSUS TRACT _ <br /> -.. ------ qG -----c------------•-------- <br /> Owner's Namer ' Phone <br /> ------------ = <br /> t <br /> Address �. <br /> � -------� City <br /> �s 1 f <br /> Contractor's Name -------- - ------ --- ----------- ---- -- ---------------------.License# ��--- Phone <br /> Installation will serve: Residence*partmeent House-E] Commercial :❑Trailer Court ;❑ <br /> Motel ❑Other ------------- ---------------------- <br /> I <br /> � I ,;: i r� ' <br /> Number of living units:----I----- Number/of bedrooms --_- _Garbage Grinder ----------.- Lot Size _x_ -/_-.-_-_--_--_-.-.. <br /> Water Supply: Public System and name---------------- -------------- <br /> �----------------------------I--------------------------- -------------------Private <br /> t <br /> Character of soil to a depth of 3 feet Sand❑ Silt fl Clay❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan EJAdobe Fill Material -_--_-..___ If yes,type ---------------------------- <br /> e ' (A <br /> (Plot plan, showing size of-lot, location of system in relation to,wells, buildings, etc. must be placed on reverse side.) N <br /> 4 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted ifJpublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT/] SEPTIC TANK'[ ] Size----------------------- ----------------------- Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material\-A--------------- No. Compartments ------_-.._...----.. <br /> Distance to nearest: Well ------------------------------------Foy Foundation ---------------------- Prop. Line --___.- .............. • -•i <br /> LEACHING LINE [ ] No. of Lines ------------------t---- Length of each line------)--- - y Total Length ._..------___--__--....._-_- <br /> - - <br /> D' Box ------------ Type Filter Material----��-_---------Depth - - -- ------ -- <br /> FINM terial -------------------------------------------- <br /> Distance to neares-t: Well ------------------------ Foundation': _: ._..___ Property Line -_--_-..-.._--.__..----- <br /> i <br /> SEEPAGE PIT [ ] ` . Depths _____.._____ Diameter ---------------- Number --- ...__.- r. Mack Filled Yes ❑ No �❑ <br /> Water Table Depth ---------------------Rock1 Size f , 1 <br /> { ,, �. .• , <br /> Distance to nearest: Well _-______�-.-T-----------------------Foundation ..---_.-__----P ep Line -_------------------ <br /> PAIR <br /> _------._-___..__-_ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# .-_._--_._------------------- __-._ -.- Date -_-_--__----_--_--_.__.-__-_-_-_-) <br /> Septic Tank (Specify Requirements) -------------- �-�q��.= - ----- <br /> Disposal Field (Specify Requirements) -'-- --__6-_V--_-- -------------- <br /> - <br /> ._-_-___-_ <br /> ------------------------------------------------------ ---------------------?. ------X_1- ------- -- ---- ----- "_ .. <br /> - - - ----- ---- - ---- --- - --- --------- - <br /> ------------------------------------------------------- ------------------------ --------- -- - -- ----- -------------- <br /> ' (Draw existing+and require t adc itiionn 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 Rulesana'Regulations of, the fan.)oaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: y " 's <br /> "I certify that in the performance of the work for which this permit is issu4 I shall not employ any person in such manner <br /> as to become subject to Workman'ts Compensation laws of California.' 1 <br /> ' <br /> Signed ------------------ ---------1 Y.Y -- ------ Owner i <br /> BY ----------- ------ f---- _ ---------A---- Title <br /> - -- -- --------------------------------------------------- <br /> (If other n owner) _ _ _ -4 _ _ { <br /> FOR DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED BY '` <br /> ---- �-- ---- =- --------- --------------------------------------------`----------------------------- DATE .----------- - <br /> BUILDING PERMIT ISSUED ------------------------- --------------------------------------------- ----1----------------------DATE ---------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------- --------------- ----------- <br /> ------------------------------------------------------ ------ --------,------------------------------------------------------ <br /> ------------------------------______________ _____________________ __ <br /> ------------------------------ ___ _ _ _ __ -__ _. _-_-_-__-__----.--_--------__------________------+------------_--------_..._________ _.-------._ _--, <br /> Final Inspection bY:'- -- =---- -- --- -------Date _-- <br /> -- ...._ _ f <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />