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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------------------- Permit No. . ....... ------ <br /> (Complete <br /> -- ---(Complete in Triplicate) <br /> i ------------------------------------------------- -------4 Date Issued <br /> ' This Permit Expires i Year From 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 ADDRESSAOC ION ` -- `'= --- ---- ---- ---------- CENSUS TRACT ------------------------_ <br /> Owner's Name ----------------- --- Phone ------•---- <br /> - �.. <br /> Address ---- ---------- -- ---r -r - -•: -----f--�-- Ci -- �r- -- -------- - ----------- <br /> Contractor's Name - --- ----------------------- - -------------- <br /> .License # -�t� �Y . Phone --------- --------------- <br /> Installation will serve: 'Residence []Apartment House^❑ Corrimercial :❑Trailer Court ❑ <br /> w'} Motel El Other ----___ {'� <br /> t <br /> Number of hiving units:----f--- Number of bedrooms _�__----_Garbage Grinder Lot Size ---' -------------------------• ---- <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private <br /> Character of soil-to d depth of 3-fee' t: Sand❑ Silt❑-- Clay,.❑ Peat-E] 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 /> 1 <br /> NEW INSTALLATION: (No septic flank or seepage pit permitted if public sewer is available within 200 feet,} # <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ Siie-----`----------------------------------"''---- Liquid Depth -------------------------- <br /> Capacity --- Type ---------------- --.Material------.-- ------ No. Compartments -----.----------_---- <br /> p Y - -----------:,- Yp Q <br /> l ` Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line __-.------------------ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------------- <br /> 'D' Box Type"Filter Material ----------- Filter Material ------------------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ---------.------_------ <br /> SEEPAGE PIT [ <br /> f ' <br /> ] Depth <br /> ---------------- Diameter ---------------- Number ------ ------=------------- Rock Filled Yes ❑ No �❑ <br /> } Water Table Depth -------------------------------------------------Rock Size ------------------- <br /> 1 <br /> Distance to nearest: Well ----------------------------------------Foundation ------------------.- Prop. Line _------------------_ <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------I <br /> 1 <br /> SepticTank (Specify Requirements) --- ---------•-------------------------------------------------------------------------------.-------------------------------------- -------- <br /> Disposal Field ecify Requi(eme } ------------------ <br /> ----- <br /> --- ------------------------------------------- <br /> A <br /> ------------- --� ; j <br /> ----------------- ---------- ---------- <br /> ----- -- ----- -- ---------------------------- --------------------------------------------- <br /> ------ (bra C <br /> -- - - - - - - - - - <br /> - - ---- ---- - ------- <br /> j (bra 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 ject to Work 'sLCompensation laws of California." <br /> Signed ------- - -- --- - - - -- -------- -----------------------------. Owner <br /> BY - --- ------ -- ------------ --------- -- <br /> Title--- --- ------ ------------------------ ---------------------- <br /> (If other than owner ; <br /> 4 <br /> I ' <br /> FOR .DEPA1tTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------------------- DATE --------------- <br /> BUILDINGPERMIT ISSUED ---------1----------------------'---------------------------------------I---- ------------------- -------DATE -------------­---------------------------- <br /> ADDITIONALCOMMENTS -------- r-------------------------------------------------------------------------------------- -------------------------------- --------= ------- <br /> t <br /> k --------------------------7_--_---_ <br /> ----- ----- <br /> ------------------------------------------ ------- --------------------- <br /> --- - <br /> Final Inspection by: -.--- _ Date -.^- U-: ----- --- - - -------_-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> r_ <br />