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i 1 F.?R OFFICE USE: <br /> - APPLICATION FOR SANITATION PERMIT <br /> --- (Completdin Triplicate) Permit No. .__�_!_~� ... <br /> ___________________________._._______._____.______.__ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constr t and install the work herein <br /> described. This application is made in compliance with County Ordinance�- <br /> N�o. 549 and isting Rules and Regulations: <br /> - ' 5 a off - ----- ------ r�`1`" <br /> JOB ADDRESS/LOCATIO z .._ _nc _____________ ________CENSUS TRACT .... <br /> Owner's Name -`='---------------------------------------------------------------- -------Phone ------------------.-...-----•-•----- <br /> ------------ ----- ---- - - <br /> Address L - City ----- ---'--------- <br /> Contractor's Name -- ---------------------------Licen e # ------------------------ Phone -------------- <br /> Installation will serve: Residence ❑Apartment House-[] Commer 'al ❑Trailer Court ;❑ <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: k Sand'❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clair Loam,❑ <br /> Hardpan ❑ Adobe-❑ Fi Material ------------ If yes,type _______ _____________--_---- <br /> (Plot plan, showing size of lot, location of system in relati n to wells, buildings, etc..xm.ust.be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit per itted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size_______________________________________________,__ Liquid Depth _-___-____-___________.___ <br /> Capacity _16P� Type ---- --------------- Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well __ ______-________________________Foundation ____ .`­7 ________-_ Prop. Line .-_........... ....... <br /> LEACHING LINE [ ] No. of Lines _______'______________ _ Length of each line----------- __--__; ..'._ Total Length -----------.________________ <br /> 'D' Box _.- Type Filt r Material ____________________Depth Filter Materia! ---------------------._____--__------_.___-._ <br /> Distance to nearest: We ------------------------ Foundation ------------------------ Property Line ___.__.._... ........... <br /> A' <br /> SEEPAGE PIT [ ] Depth D ameter ________________ Number ----- _----_____'_____ Rock Filled Yes ❑ No <br /> Water.Table Depth - ----------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: ell ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------------------------------------------- Date __________________________________) <br /> SepticTank (Specify Requirements) ----- ------------------------------------------------------------------------------------------------------------------------------------- <br /> DisposalField (Specify Requirements ------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------- ------------------------------------------------------------------------------ ------------------------------------------------------------ <br /> ( aw existing and required addition on reverse side) <br /> I hereby certify that I have prepar this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, an Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the fo owing: <br /> "I certify that in the performance f the work for which this permit is issued, I shall not employ any person in such mariner <br /> as to become subject to Workm4 's Compensation laws of California." <br /> Signed -------------------------------------- -----------------------------------------------------•--. Owner <br /> By ------------- - Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------------;;-------- --- - �� <br /> S r =�/ <br /> BUILDING PERMIT ISSUED - DATE-------DATE ---------- -------------------------------- <br /> ADDITiONAL COMMENTS -------------------------------------------------- - <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------ <br /> -------------------------- <br /> Final Inspection bY -------------------.Date -- - ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />