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FOR OFFICE USE:r �"� '1�%S <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------- �n V <br /> ------- Permit No. __ <br /> (Complete in Triplicate) <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 insta I the work herein <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION '.--f- -�� _, -- -- -------------------------- -----CENSUS TRACT ----- '_SQ--'-- <br /> 01- <br /> Owner's Name .- _---- ---- --------- ----- -- ----- ------- --- -------------------------------- -------Phone <br /> Address -- City - --- - ------------------------------------------------ <br /> f <br /> Contractor's Name __ _ - icense # �2-7- Phone S-254-7- -_-_----_ <br /> lea <br /> Installation will serve: Residence ❑�Apartment'House Com ercial :❑Trailer Court ❑ <br /> Motel ❑Other <br /> Number of living units------- Number of bedrooms ---r�_ --Garbage Grinder ------------ Lot Size _ _ - -.-------- <br /> Water Supply: Public System and name ----------------------------------------------------- -------------------Private kN! <br /> Character'of-soil to a depth of 3 fhet: SandSilt 0 Clays❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ <br /> { _ <br /> .- Hardpan ❑ Adobe-❑ Fill Material,__m-0--- 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 seepa pit permitted if public sewer is available within 200 feet,) <br /> 1� r <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ Size_'Tr ,k-4_ _-.-. ___-""- Liquid Depth ___----------------,...__ <br /> Capacity Type --------------- Material_ G? .No. Compartments .rte-- K1 <br /> istance to nearest: Well -369_ F___________ __Foundation ------- Prop. Line __._-_.--_:___-.___--_ <br /> LEACHING LINE No. of Lines -------I---------------- <br /> Length of each line --.1AW-----_---.--_- Total Length -_-- -------- <br /> 'D' Box .^-f Type Filter Material 1 �r Depth Filter Material - - -------------------------------- <br /> b � < <br /> Distance to nearest: Well 3 ------------ Foundation ------------------------ Property Line <br /> SEEPAGE PIT [ ] Depth --------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ . No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ----------- -------------------- <br /> Distance to nearest: Well -----------------------------!...........Foundation --------------------- Prop. Line ---------------------. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _--_-_----_-_--_-_--_--_. --- <br /> SepticTank {Specify Requirements) ---------------------------------------------------------------------------------------------:---------------------------------------------- <br /> Disposal Field (SpecifyRequirements) -------------------------- ------------=------------ -------------------------------------------------------------------------------- <br /> � k <br /> F <br /> --------------------------"-----__-------------__--_----.--------_--_--_-_---__-___-_______---___---_------_--_-_--_----.----_---_-----_----_----------_----------.--_---__------.------------------------ <br /> L�--- <br /> —(Draw-existing-and-requ.ired-addition on reverse:side)•�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, I shall not employ any person in such manner <br /> as to` beco subject to Wo man's Com ensati.on laws ofCalifornia." <br /> Signed -� Owner <br /> --• <br /> BY ---- - -- ------------------------------------------------- Title <br /> --------- ----- --------------------------------------- <br /> (If the, than owner <br /> ' i-- FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- -I._-t-&.0----- --------------------------------------------------- ----------------- DATE ----I+P �� -------- <br /> F BUILDING PERMIT ISSUED ------------- ------------------------------- --------------DATE <br /> ADDITIONALCOMMENTS -- --------------------------------------------- --------------------------------------------------------------------------------------------------- <br /> --- - ------------ ------------------------------------- ----------------------- - - <br /> Final Inspestio ------Date / �---- /------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'68 Rev. 5M'' ' ' <br />