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FOR OFFICE USE: ` <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> a (Complete in Triplicate) <br /> ____________________________________ <br /> -------------------------------- This Permit Expires i Year From Date Issued Date Issued <br /> Applicibation is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> descred. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---------------C _-- .------CENSUS TRACT --------._--_.--..-_------ <br /> Owner's Name <br /> �c _ ' '� _ -- �_I �, Phone <br /> Address A-------------- city � �' <br /> Contractor's Name _-- -- f '��- �_"---- �_- -----License # � � -- -Y_ Phone ------------------------------ <br /> Installation will serve: Residege ❑Apartment House-E] Commercial ❑Trailer Court <br /> Motel ❑ Other ----------------------------------------•--- ` <br /> Number of living units:------------ Number of bedrooms ----_--_____Garbage Grinder ------------ Lot Size __________________________________________N\ <br /> Water Supply: Public System and name ---------------------------------•------------------------------------------------------------------•---------Private R f �1 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt F) Clay ❑ Peat❑ Sandy Loam []Clay Loam '❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ____________________________ \l <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 -----------.-------------- <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 to nearest: Well ________________________ Foundation --.--------------------- Property Line ..__..... .............. <br /> SEEPAGE 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 /> (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 /> 111 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 ------------------------ ------------------ --------------- .0_(�----. Owner <br /> By --- --- -- ------- -- itle ------, ltl!t---------------------------------- <br /> (If other than owner) <br /> 49 FOR DEPARTMENT USE ONLY rr�� <br /> APPLICATION ACCEPTED BY -------------------------------------------------------------- DATE Z .7 ------------ <br /> BUILDING PERMIT ISSUED - ------------------------- - - -------------------------------------------DATE ----------------------------------------' <br /> - --------------------------- -- <br /> ADDITIONALCOMMENTS ------------------ --------------------------------------------------------------------------------------------------------------------------------•-- - --- <br /> -------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- --- ----- <br /> ---------------------------- --------- _ ---- <br /> --------------- <br /> --- - --- ---------------------------------- -- <br /> Fina! Inspection by: ------ ------- ----------------------------------------------Date - --------� ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.9 1"68 Rev. 5M <br />