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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> - <br /> ---------------------I---------------------------------- <br /> (Complete in Triplicate) <br /> Date Issued -----_- �_-�-?! <br /> --------------- -- ------- ---------------------------- This Permit Expires ] Year From Date Issued <br /> Application is hereby made to the S n Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made iN_ compliance wi ounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION �� � f /------------------------------CENSUS TRACT _� y <br /> Owner's Name ------- ------------- -------------Phone ------------------------------------ <br /> Address -------------- /��� 4 , -------- - --- -- ----- ----.. City - -------- -------- <br /> Contractor's Name -------- --- <br /> License # �I ✓� y Phone -------------•---------- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -- ---- <br /> Number of living units:-.-_1.----- Number of bedrooms ._._.Garbage Grinder ------------ Lot Size ------------------- ------------------------ <br /> Water Supply: Public System and name ----------------Aw---------------------- ---------------- --------------------------------------------Private,& <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan�V 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 f ] SEPTIC TANK'[ I Size_A/.CP`- X-- �r Liquid <br /> i <br /> Depth -_--------------i-- <br /> ----- <br /> Ca acitYType Material_-- No. Compartments ----�--.-.------ <br /> O <br /> - p. Line -_--_. _ -.--__--Distance to neare : Well -------.-_�'------------------Foundation _-.--/_0-.---_----- Pro <br /> LEACHING LINE No. of Lines .........:P Length of each line.--------- -------- Total Length ---- ------ <br /> 'D' Box -----1----- Type Filter Material _--- �._Jp_.--_Depth Filter Material ------- -------------•---------------- <br /> Distance to nearest: Well -------- Foundation ------/_Q------------ Property Line -_ 5----------------- <br /> SEEPAGE PITDepth --.-a_ -�-_ Diameter ----- Number -----__--¢2------- - Rock Filled Yes [A No (I <br /> Water Table Depth ---------------- ---------------------------Rock Size -- <br /> Distance to nearest: Well -------------/_f2Z>-...............Foundation _-_10--t-_---- Prop. Eine ---_-S____._._-_-.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ------------------.---------------) <br /> Septic Tank (Specify Requirements) -------- - -------- ---------------•--------------------------------.. ---------------------- <br /> Disposal Field (Specify Requirements) ----------- --------------------------------------------------------------- ------------------------ <br /> ------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------- <br /> --------------------------------------------------------------------------------I------------------------------------------------------------------------------------- <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 Sari 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----------------- ------------------------- Owner ILr�7 <br /> By ------- - -------------------------------------- - -- ------ Title <br /> -------------- ------------------------ <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 19 APPLICATION ACCEPTED BY - 7Z-._--__.--_ <br /> DATE <br /> BUILDING PERMIT ISSUED ---------------------------- --DATE ------------------------- ----------------- <br /> ----------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------- ------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------- ---------------------------------------- <br /> --------------------------------------------- -- - -- ---------------------- -- -- <br /> ------------------------------------------------------------------------ <br /> ------------ <br /> Final Inspection by: ----- ------ Date - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />