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r , <br /> FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No: _ J:-.JE,-_._. <br /> t (Complete in Triplicate) <br /> ' This Permit Expires 1 Year From Date Issved Date Issued <br /> ---------------------------•-------------------------- } <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance ith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---� --�r--✓��---,�_.•--- ---------------------------------------------------------------CENSUS TRACT --•-----------_------_ <br /> Owner's N6me ------- 1 --•- <br /> -►-=-------- - ------ -- -- ----------•--------------------:=------ :-:,Phone:..::Phone -------------•--...........-........ <br /> Address ---------------- --- .. ---- ---------- City ------- ----------------------. ....... <br /> Contractor's Name tr ------License # 3 ------- Phone <br /> Installation will serve: Residence Apartment House f❑ Commercial❑Trailer Court 60 <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 F] Clay ❑ Peat[I Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan L� .. 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 f ] Size---------- ------------------------------------- Liquid Depth --------------..---------- (Ui <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 /> Distance <br /> ----------- -•---- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line, --------- .............. <br /> SEEPAGE PIT [ I Depth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> .Water Table Depth ---=----•------ --------------------------------Rock Size -------•---•----------------•--- <br /> Distance to nearest: Well -----------------_--------------------Foundation ----------- ------ Prop. Line -------------......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- bate --------...._.--------------------) <br /> I <br /> SepticTank (Specify Requirements) -------- -------- ------------------ ------------------------------------------------------------------------- ---:_ ------------- <br /> Disposal <br /> ----------- .. <br /> 1 <br /> Disposal Field (Specify Requirements) ... --- ----- - ----- ----- ---- - - ------- -------.- ----------- <br /> i I 2 ------ <br /> -----------1-0,6------- - ----- �... = == r <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 performancerof the work for which this permit is,issued, II shall not employ any person in such manner <br /> as to become subject to Workman's ensation la of California." <br /> Signed --------------------------------------------- ------- ----------- - -- --- Owner � <br /> - le <br /> - <br /> By ------------------------------------------------ . •--•-- <br /> (If other than owner) <br /> 1 -FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------------- DATE <br /> BUILDING PERMIT ISSUED ------- '-------------=-- - ------•----------•-•---------------- --DATE ------------------•------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------ ---------------------=--------------------------- <br /> --------------- --------------------------------- -------------------.----------------------------------------------------------------------------------------------------------------- -- ='----- <br /> ------------------------------ --- ------ <br /> Final Inspection byc --- Date -� - -� __ . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />