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FOR,pFFICE USE: <br /> `�. <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- ----------------1------------ Permit No. <br /> - ------------------ <br /> [Complete in Triplicate) <br /> ----------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued _ =______.. <br /> --------------------------- ----------------------------- <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/LOCATION . ._ !__ ��, �� --------------------- �"" CENSUS TRACT <br /> Owner's Name -----t/ ------- _ X 1....................... ----------- Phone ------------------------------------ <br /> Address City - <br /> ------------- <br /> __ // <br /> Contractor's Name400 <br /> tiC ......License # •� 1 'Phone <br /> Installation will serve: Residence Apartment House❑ Commercial .❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:_____r_____ Number of bedrooms _3------Garbage Grinder ------------ Lot Size --- _ _________ <br /> Water Supply: Public System and name ---------------------------------------- ----------------------------- ---------------------------------------Private' <br /> Character of soil to a depth of 3 feet: Sand b Silt ElClay E] 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 '+f public sewer is available within 200 feet,). <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size _� ___.�__ X---- ___ _ <br /> _____ Liquid Depth _ _ ___________________ <br /> Capacity 1 _�___ Q Type �+- . _ Materiai____��o. Compartments __,2..._------------ -D <br /> Distance to near st: Well _._________s�__t_______________Foundation __.�lT__f___________ Prop. Line __. ---------------- 9 <br /> � <br /> LEACHING LINE [ No. of Lines --------%3_______.__ Length of each line--------- ............. Total Length -------- 0 <br /> 'D' Box _-I...... Type Filter Material ----!--R------Depth Filter Material -------- ---------------------------- m <br /> - Property Distance to nearest: Well ______�a___________ Foundation -/0-------_.__ Pro p tyLine _5----------­----- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------- ---------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well _____:________________________________Foundation ----- -------------- Prop. Line ------I___________-_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit s# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --------------------------------------------------------------------------------------------------------------1----------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 subject to Workman's Compensation laws of California." <br /> Signed ------------------------------------ - - Owner <br /> 6 <br /> By ------------------------------------------ J = Title <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- --------------------------------------------------------------------------------- DATE __ " ------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------•-------------- ------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- <br /> ---------- --------------------------------- -- -------------- ---- ------------------------------------------- ------------------ -- -- ---- -------- ----------------------- --------------- <br /> ------------------------------ - - --------------- - ---------------------------------------------------------------------------- "F ---------- <br /> FinalInspection b -------..: - ----------------------------------------------------------------------Date -- - -- ----- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> t � - <br />