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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> -- --------- <br /> ----- - - <br /> - ----------------------------------------------- <br /> (Complete in Triplicate) <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 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/LOCATION7_f____ _._'z� ___------ -r------ --"- - ---- `L -----.---------------CENSUS TRACT _ `�- ----- <br /> Owner's Name/ -_ ,-- L --------------------------- -------Phone <br /> 111 <br /> Address -- ---- ��-- City - -------------------------------------------------------- <br /> Contractor's Name _.. - ---- ---- -- - --- --- -- ,..License # _JY739yPhone --------------------------- <br /> Installation will serve: Residence* artment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other ------------- ------------------•----------- <br /> Number of living units:------ -___ Number of bedrooms ?�-----Garbage Grinder ------------ Lot 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 seepage pit'permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth -------------------------- U1 <br /> Capacity ------------------ Typei--------------- Material---------- ----------- No. Compartments ------•----_--------- � <br /> ` Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -----------.----------.... V <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------- �! <br /> Distance to nearest. Well ________________________ Foundation ---.-------------------- Property Line ___.__-.__-_--___------_ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -----------------------•----•--- <br /> r <br /> Distance to nearest: Well ______________________________________Foundation -------------------- Prop. Line --__.--___-____.______ <br /> REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________j <br /> Septic Tank (Specify Requirements) ------- ----------------- <br /> Disposal Field (Spe cify a uirement �01- - --------- <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 su0_thanow�ner) <br /> a ' Com ensati.on laws of California." <br /> Signed -------------- - ---- - - ----------------------------- Owner <br /> By ----- ----------- Ti <br /> --- ----------- - ------------------ ----------------- <br /> ------ -------------------------------------- <br /> (If <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------- ------ ---- -------------- ------ --------. DATE . 1- //y ------�-- <br /> ---------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------- ---------------------------------- ---- ------ ------------------------------------------------------------- - <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- <br /> ----------------------------------------------- ------- ----------------------------------------------------------------------------------------------- ------------------------- ---------•- <br /> -- - --- <br /> Final Inspection by: - - ------------------------------------------------- ---- - -patel.-�-�" y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />