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�- FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- �--�.__-.�`�'-�------' Permit No. .(�-��_��� <br /> - -------- (Complete in Triplicate) <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> --------------------------------------------------------- <br /> + <br /> Application is hereby made to the Son Joaquin Local Health District for a per 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 /> 3,Z 67 CENSUS TRACT --------------•------ <br /> ----- <br /> JOB ADDRESS/LOCATION .---- - . -------- <br /> Owner s <br /> Name - <br /> r -------------------- <br /> Phone -_---- ----------- <br /> -- <br /> 1 <br /> Address ' 4 City -- -eL------ -------------- <br /> - <br /> Contractor's Name - <br /> License # ------------------------ Phone ---------- ------------------- <br /> - -------• ---------- <br /> ---------- <br /> Installation will serve: Residence Ri-Kpartment House❑ Commercial ❑Trailer Court C] <br /> Motel ❑ Other ---- -------------------------------------- <br /> Number of living units:--.--f------ Number of bedrooms _-2 Garbage Grinder -"W- Lot Size ----- -------- <br /> Water Supply: Public System and name ------------------ -- - ------- -"•--"""""- - <br /> -------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Cloy Loam ❑ <br /> Hardpan ❑ Adobe '[�9,—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 /> [ ] <br /> SEPTIC TANK'[ l Size Liquid Depth ---------------- ------ <br /> PACKAGE TREATMENT <br /> ------ <br /> Capacity - Type -------------------- Material--------------------- No. Compartments <br /> Distance 'to nearest: Well ------------------------------------Foundation _____-.--___--------- Prop. Line ._______.:--.___-- <br /> LEACHING UNE [ ] <br /> No. of Lines -------- Length of each line---------------------------- Total Length ----------- •-- <br /> ------- - - - <br /> nce 1--------- Type Filter Material --------------------Depth Filter Material ----------------------------------- •------ <br /> ---- Foundation ------------------------ Property Line. ------------------------ n <br /> D' ox <br /> D�sta "to nearest: Well ___________________ <br /> SEEPAGE PIT [ ] Depth --------------- Diameter -----------.---- Number ---------------------------- Rock Filled Yes ❑ No i0 <br /> i R <br /> Water Table Depth Rock Size ----"" <br /> ----------------------------------------- <br /> �) -- Pro Line ---------------------- <br /> REPAIR/ADDITION <br /> ----------------- <br /> Distance to nearest: Well ______________ __________ <br /> -'------------Foundation ------ ---------� p. ---- <br /> REPAIR/ADDITION(Prev.:Sanitation Permit�# --------------------------------------------- Date.-------------------•----------•---) �'� <br /> { ----------------- - --- Y <br /> I Septic Tank (Specify Requirements) -------- - If <br /> Disposal Field (Specify Requirements) ------- <br /> Q �� 3 �-Sr <br /> --------- --------------------- ------- <br /> ---------------------------------------------------------------- <br /> ' ____________________________________ N _' _ _ <br /> - ------------------------------=---------------------------- <br /> i (Draw existing`and required addition on reverse side) <br /> lI 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,sand Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: ' <br /> F "1 certify that in the performance`of the work for which this permit is issued, t shall not employ any person in such manner <br /> I � l <br /> as to become subject to Workman,s Compensation laws of California." _ <br /> Signed ------------------------------- Owner <br /> --------------------------- - <br /> B <br /> -------- Title ---------------------- --------------------------------- <br /> Y _ <br /> other than owner) <br /> t) FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .- -_ __ -------------------------- <br /> DATE ----?`3--y-----•--------- --------- <br /> --- - - DATE ------------------------------------------- <br /> BUILDING PERMIT ISSUED -,------ ------------------------ -------------- <br /> ADDITIONALCOMMENTS ---------= --- -- - -- - =- ---------- ---------•---------- -- ------ ------ --- --------- ---------- -------------------- -------- ----- <br /> is ---------------------------------- <br /> ------- -- ----- <br /> ------------------------ ------ -------------------------------- ---------------------------------------- <br /> -------------------------------- - <br /> - --- - -----------------------------------= ---------- - <br /> ---- --Date -------- ------------------------------ y <br /> Final Inspection by: -- � -- -- ------------------------------------- - - --------�------- -------- - - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t E. H. 9 1-'68 Rev. 5M <br />