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FOR OFFICE USE: APPLICATION FOR_SANITATION PERMIT ' `rc <br /> Permit No - ' <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> ----------------------------------------------------- <br /> azr� <br /> pp kation is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application i3smade in compliance with County �No.49 existing Rules and Regulations: <br /> JOB ADDRESS/LOC ION:�JC�x-- '-------------------CENSUS TRACT -------------------------- <br /> ------------ <br /> - <br /> ------------- -----. <br /> TI <br /> Name � �Ct-r^' Phone 'r - TTT-16-­ <br /> --------------------------------- <br /> Owner's I <br /> Address ----- t - ----- ---- _ Cit ------------ --- ' <br /> df <br /> i Contractor's Name ------ ---- .License # � Phone 1 <br /> i <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Num ber of living units;------f---- 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 0 Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe-❑ Fill Material ____-------- If Yes, type --------------------------- <br /> J <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,) �i <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:( ] Size------------------------------------------------ Liquid Depth .--------------------.-- -- i <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 ---------E Type Filter Material --------------------Depth Filter Material ------------------------------------•-• <br /> Distance to nearest: Well --- --------------------- Foundation ------------------------ Property Line ----------------_- <br /> SEEPAGE PIT PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No I❑ <br /> Water Table Depth ---.Rock Size ------ ------------------- <br /> Distance to nearest: Well ---------------------------------------Foundation -------------------- Prop. Line ----_----------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------.--------------) <br /> Septic Tank (Specify Requirements) --------------------------------------- ------------ ---------------------------- - ---------------------- <br /> Disposal Field (Specify Requirements) -----::-------------------------------------------------------------------------------------------------------------•--------------- <br /> - -------------------- -- --- --------------- ....... <br /> ---------------------------- ---- ----- ------------------------------------------------------- ------------------------------------------------------------------------ -------------- <br /> I (Draw existing and required addition on reverse side) . , <br /> I he by 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 cetr ify 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 <br /> Signedbecome subiect to Workman's Compensation laws of California." <br /> ------ - - ----- - -------------------------------- Owner <br /> BY �. --------------------- Title - " a <br /> ---------------- ---------- <br /> (If other than owne ) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - -- - - -------- ----- <br /> DATE -6-=I r6-----•------------------- <br /> - - ------------- -------------------------------------------- <br /> ------ <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------- -------------=--------------DATE <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------- <br /> ---- -------------------------------- --------------------------------------------------------------- ------------------------------------------------------------------- <br /> --------------------- <br /> ---------------------------- <br /> ------------------------------------ -------------- <br /> Final Inspection by: ------- ---------------------------------------------------------------------------Date=1c _ <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.I!9- 1-'68 Rev. 5M _ - <br />