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FOR OFFICE USES=- APPLICATION FOR SANITATION PERMIT <br /> _...... . .............................:...... <br /> Permit No. .....___.....$... <br /> (Complete In Triplicate) <br /> M Date Issued - - .. <br /> ................................................:...... This Permit Expires ] Year From date issued r <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. 5a9 and existing Rules and Regulationst <br /> JOB ADDRESS/LOCATIO _11�a........ :..... S // �P. ...........................CENSUS TRACT ......... <br /> Owner's Name .............. .. ....... .•----•----•-------:..---------.•.......__.....__......Phone • ................................ <br /> a <br /> . .. ...--- <br /> Address ..................... _..... <br /> Contractor's Name .._. ------•------•--------_-•--•--.......License # Phone ._.��. <br /> Installation will serve: Residence❑Apartment House 0 Commercial[]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: Sand❑ Silt Clay ❑ Peat Q Sandy Loam 0 Cloy Loam 0 <br /> Hardpan ❑ Adobe 0 Fill Material ............ If yes,type ............... ............ <br /> [Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r*) <br />'M NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �) ; <br /> PACKAGE TREATMENT [ ) SEPTIC TANK fi ] 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 fine---------------- <br /> _............ Total Length ............................ <br /> D' Box Type Filter Material ....Depth Filter Material .............. <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ---.._..... ............. <br /> SEEPAGE PIT [ 1 Depth -------------------- Diameter Number --------------.............. Rock Filled Yes ❑ No i❑ 1 <br /> Water Table Depth -------_---•----__ ..................Rock Size -•--------------- -------------- <br /> Distance to nearest: Well ------------- ........Foundation ..................... Prop. Lina ...................... <br /> REPAIR/ADDITION[Prev. Sanitation Permit# -. ��a..��._ /eC,Date _______________________________ <br /> SepticTank (Specify Requirements) ----- .......................... .........,.......... .......................................................................___......... j <br /> - I <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, t shall not employ any person lin such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------_-----------•--... --- -- --------- -------------------------------- Owner <br /> By <br /> -------•-------• - --...---- . •tle __ <br /> - - --- ------------ - <br /> (if other Than owner) 6 <br /> iF R D PARTM T USE ONLY <br /> APPUCATION ACCEPTED BY _.-.... _ DATE ._...--.-2. •-- --- - ------------ <br /> . ---- • ------- - --- -----�- - - <br /> BUlLDING PERMIT ISSUED ....................... ...... ---- - -._.....-.•-.. ---------...--- DATE _...__...._ .__..:_.. <br /> ----- <br /> ADDITIONAL COMMENTS ----- ......... ---------•----------•--------------------- .... . ----._.._-.-- <br /> -----------• -----------•---•--•----------••--------- ----------------------------------------------- .................................................. --------- <br /> ----------- •----------- <br /> finalInspection by- ----------------- ............................ ......... ------------------Date .... _:. _ -----........._. <br /> EH 13 24 1-68 Lev. 5n SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />