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FOR OFFICE USE ; <br /> APPLICATION FOR SANITATION PERMIT <br /> '------�- ---- --- <br /> f ` (Complete in Triplicate) Permit No. <br /> ------ --- -------- ------ --------- ----- q <br /> ------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> ---- -- <br /> tw ' <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 - -3--:- -- .-----CENSUS TRACT ------- -----`--------- <br /> Owner's Name - � ------------------------------ --- -------------------- Phone ���� - ��/ <br /> - - --- ---- - --- <br /> I Address ------------------- a�_ 3-------- � City _. f <br /> Contractor's Name S . - ----- Phone 7- = /Y ?� <br /> 1nstallation will serve: Residence'j2CApartment House❑ Commercial❑Trailer Court ❑ <br /> ti 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 ❑ Sandy Loam ❑ Clay Loam (] <br /> Hardpan ❑ Adobe Fill Material ------- If yes, type <br /> r r <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on'reverse side.) 4 <br /> 4 s,i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,)" TN <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.{ ] Size------------------------------------------------ Liquid Depth ---------------•----.----- .l�. <br /> � W <br /> Capacity ---------------------Type -------------------- Material---------------------- No. Compartments -------•-----•- ----- <br /> � <br /> r Distance to nearest: Well ------------------------------------Foundation --------------I------- 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 <br /> _-_-_ _Distance to nearest: Well --------------_------___ Foundation ------------------------ Property Line ________-________-_____ <br /> SEEPAGE PIT Depth -- Diameter -------- ------- Number -{- ------------------------ Rock Filled Yes ❑ No <br /> Water Table Depth -----------------------------------------------Rock Size -------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------- ----------- Prop. Line _________-_______-.___ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> ISeptic Tank (Specify Requirements) ---------------------------- ------------ --------- ---------------------------1_------------------------- ---- - ------------- <br /> k Di osal field (Specify quirements) l -------- ----- ------------ - _ ------ <br /> �i ------- •- ---- <br /> } -- -- ------- <br /> -------------------------------------- ---- --------------- ------------------------------------ ----------4----------------------- ----------------------- ---- ---------------------------------------- <br /> t (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 accordancewithSan 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 o he work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to bec su 'ec) td W man' mpensati la s' of California." I <br /> ��.­ <br /> Signed -------- ------ wner <br /> By ------------------------------------- ------- Title -------- ------------------------------------------------- ------------ <br /> - ----------------- --- -- <br /> ---- ---- --- --------- - <br /> (If other than <br /> EOR :DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . fill/- =--------------------------------------------- DATE f�' f �7 --------------- <br /> BUILDING PERMIT ISSUED - ---- ---DATE ------------------------------------------- <br /> -------------------------------- <br /> ADDI7iONALCOMMENTS ---- ------------- - ----- ------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> � ;<. <br /> --- ---------------- <br /> ----------------------------------------------------------------- ------------- ------- <br /> Final Inspection by: - ---- --------------- Date:__ C-�._ ._ __ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M r-r" <br />