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FOR OFFICE USE: <br /> .P APPLICATION FOR SANITATION PERMIT <br /> -------IL--------------- ----- Permit No. <br /> (Complete in Triplicate) <br /> ----------•------------ --------------------------------- <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 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 /> JOB ADDRESS/LOCATION ._ �- S____, -' ---------_CENSUS TRACT ----------------- -------- <br /> Owner's Name - ( -__ -------------------------------------------------Phone Yr*�_ S��o <br /> +"�f� --•----------------- <br /> Address --- --------------?C)P- -------- -----'---. City . <br /> Contractor's Name ------------- -- � ----- .54 `?6.d7. <br /> ----- ------ -- - �--���------------------.License # ��,►----� Phone -- -- --- ----- -- <br /> Installation will serve: Residence YApartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other --- ------------------------------ <br /> Number of living units:_________ Number of bedrooms __,_.Garbage Grinder ------------ Lot Size __-�E- __ *� ______--_----- <br /> Water Supply: Public System and name ----------------------------------------------------------------- --------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ..__-.__--._ if yes,type ____________________________ <br /> (Piot 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:[ ] 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 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to,nearest; Well _______________ ____ -.__-__---Foundation -------------------- Prop. Line ______________-_--__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---__---__________________________} <br /> Septic Tank (Specify Requirements) ---------------------------- D - ----------- � - <br /> Disposal Field {Specify Requirements) --------------- - [-------- - ------- -� -�'t----- -- - ---- ---------- <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 Sero 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------- Owner <br /> ---=---- --- <br /> BY ---- --- ---------- 01"r___ Title 5; <br /> ---------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ------------------------ -----. DATE ---3 ------�--------------- <br /> BUILDING PERMIT ISSUED -------- .--.---DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------- <br /> -------------------------------------------------------------- <br /> - -- ------------------------------------------------------------------------ ------------------------------- - --------------------------------- <br /> ----------------------------------- --- <br /> Final Inspection by: Date ---- ----- - -------- -------------------------------------------------------------------------------------- <br /> - -----------•------- <br /> SN JOAQUIN LOCAL HEALTH DISTRICT------------------------------------- ----------------- <br /> -------------- <br /> E. H. 9 1-'68 Rev. 5M c,2r <br />