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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------------------- Permit No. .(s-zay. <br /> (Complete in Triplicate) <br /> ---_----_---_----------_------_--------------------- This Permit Expires i FYeor From Date Issued Date Issued.._/ - `�- <br /> - e77a -,rs <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 existi g Rules and Regulations: <br /> � � �� <br /> JOB ADDRESS/LO TION . ----- -- -- --- :-4 ----------- -hf:-L�JX <br /> Jfr�< -- --------------------CENSUS TRACT __.-------------------- - <br /> Owner's N _` = --G*3�_ <br /> --: Phone -------------------- <br /> Address V"� - ,.- " City � - <br /> Contractor's Name --- ------=- ------------ _------License # Phone ------------------------------ <br /> Installation will serve: Residen e eApartment House❑ Commercial :❑Trailer Court ',❑ <br /> - -Motel ❑Other—_� ._. ._ <br /> -------------------------------------------- <br /> Number of'living units:---oZ--- Number of•bedrooms ________Garbage Grinder ---------.-- Lot Size ___ '' _ �.--____ <br /> i t-• - <br /> Water Supply: Public System.and name ---------------- =-......---'- r-------------------------------------------------- Private <br /> Ur <br /> Character of soil to a depth of-3 feet: -Sand'❑-° Silt F1 Clay E3Peat ElSandy Loam Clay Loam <br /> r Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot,j6cation-of-system An 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 [ I SEPTIC TANK'{ j Size------------------------------------------------ Liquid Depth _._________________.,___-. ] <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 /> 'D' Box ..---------- Type Filter Material --------------------Depth Filter Material --------------------.---------------- <br /> . <br /> u Distance to nearest: Well ________________________ Foundation ------------------------ Property Line, __________________--.--. ,1 <br /> i <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock t=illed Yes ❑ No .i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ---___-_-----__-- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------- ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# -------------------------------------------- Date ---------------------_---_--_•_-_-) <br /> Septic Tank (Specify Requirements) -------------------- - <br /> --------------- _ -- <br /> Disposal Field (Specify Requirements) ___ - ! ---- -_-.- � - ----' --------------------- <br /> -------------- <br /> --------•------ ---- <br /> f `! � - r-s t/ � <br /> ----------------------- <br /> rw <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 s ct to Workman's Compensation laws of California." <br /> Signed ---------- ----- Owner L. <br /> BY ----- - -c Title ----"e_ ----- <br /> ---------------------- <br /> (If other than owner). <br /> '1-w� FOR,DEPAII:TMENT USE ONLY J <br /> APPLICATION ACCEPTED BY -----------------------------------------------=-------------- DATE/,2----2_ ------ <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------- - -------------------------DATE ---------- -------------------------------- i <br /> ADDITIONALCOMMENTS ---------------------------------------------------I----------------------------------------------------------- --------------------------------- <br /> -= -------------------------------------------- --------------------------------------------- ------ -------------------------------------------------------------------- <br /> - --- ------------- <br /> Final Inspection by: - _ - - ----------------------------------------------- Datef _&------------ <br /> ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />