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FOR OFFICE USE: <br /> 0QAPPLICATION FOR SANITATION PERMIT �� l�� <br /> = "' Permit No. - - <br /> (Complete in Triplicate) . _-------- - <br /> ---------------------------------------------------------- <br /> ________________________-_.__-________________.______ This Permit Expires ] 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 ----------•---------------•--------- <br /> 1 - <br /> Address � � ----------- City - ---------------------- ----------- <br /> Contractor's Name -----lL� License # . _-__ Phone% - f <br /> Installation will serve: Residence <br /> �Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units:_-__1__ Number of bedrooms ___Garbage Grinder -------- -_ Lot Size!- __ L�_ )_________ <br /> Water Supply: Public System and name ------------------------------------------ -------------------------------------------------------------------Privatex <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 /> (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 [ I SEPTIC TANK'[ ] Size----------------------------------- ------ Liquid Depth ------------ ------------- \ <br /> �y Ca acit <br /> //1�6— p Y --------------------- Type --------------------- Material------------------- - No. Compartments ----------- <br /> ----------- <br /> w 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 /> _DistDistance <br /> ance to nearest: Well ________________________ Foundation ------------------------ Property Line, ---------.______---_-_ <br /> + SEEPAGE PIT [ ) Depth ____________________ Diameter ________________ Number ----- ---------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth _______________g�t---------------_......._.Rock Size -------------------------------- <br /> r Distance to nearest: Well ----------------7--------- --.---.....Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit 5# -------------------------------------------- Date -----.---------_-----------------_) g <br /> Septic Tank (Specify Requirements) -------------- �� _------------�lr---- --. ---- _ ------------------ <br /> ----------- I ... <br /> Disposal Field (Specify Requirements) �� g �a'C1f ------------ "1 <br /> --- ---- <br /> ---------------------------------------------------------- -------------------------------------------------------- ---------- -------------------------------------------------- <br /> A------ -------------------- ----------------- - ---------------------------------------- --------------- ------------------------------------.---------- - ------ <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 performan of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to b e s bjectNark 's Compensa '. laws of California." <br /> Signed ------,--r----- ----- -� t� Owner <br /> ------- r <br /> BY ------------r- ------------------------- - ---- -- ------- ---- ---- -Title -------------------- i <br /> (If other than �e <br /> FOR PARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY _ R DATES lV 7 <br /> - -- -- -- -------------------------------- <br /> BUILDING <br /> PERMIT-.ISSUED -------------- `� ------DATE - ---- ------------------ <br /> -------------- <br /> ---------- ---------------------------------------------------------------- --- <br /> ADDITIONAL COMMENTS ---x --°`-- ----------------------- <br /> ' ' <br /> ----------------- ------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------- <br /> ------ ---------------------------------------------------- ----------------------- <br /> Final Inspection b _____Date _____ o <br /> --- ----------- <br /> PY- ------------------------- -- -------- 1�� ------------ --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />