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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ......................... <br /> .................... ... <br /> ............ ................................ <br /> (Complete in Triplicate) Permit No. ... .............•--- <br /> .. This Permit Expires 1 Year From Date Issued Date Issued .. .a�..... .. <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 O dinance N . 549 and existing Rules and Regulations: <br /> +/0&. <br /> l <br /> JOB ADDRESS/LOCATIO .-_.. -- .......................- -•. CENSUS TRACT <br /> Owner's Name ........ --•--- . . --••• - e........Phone .....................---,........Address ... ........._./41? ...---( � � City .. �. ................................................... <br /> Contractor's Name ..---......_ _ ... . ... --• _.... . ....a4.()cense # ........................ Phone .............. .......... <br /> t Installation will serve: Residence partment House❑ Commercial❑Trailer Court ❑ <br /> Motel❑Other ........... .......................... <br /> 4 . <br /> Number of living units:--- __--- Number of bedrooms .. ..Garbage Grinder ............'rot-Slie ............................................ <br /> Water Supply: Public System and name --...................-•-•...............................................:.....................................Private N <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Cla ❑ Peat El Sandy loam 0 Clay Loam [3 <br /> Hardpan p Adobe FIII 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 ore pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTICsee1 TANK Sixe.�r. 2.2 �.r `>�.~........ Liquid Depth ..,��.................... <br /> Capacity _.l. O t?--- Type art Material.....d 7 ..-._ No. Compartments .c -............, <br /> Distance.to nearest: Well ...............Foundation .......... Prop. Line .:;5�............... <br /> LEACHING LINE No. of Lines .._. -------------- Length of each line---_---.� �..- Total Length ......... <br /> 'D' Box Type Filter Material ....5... .......Depth .Filter Material ...A.7................................ <br /> Distance to nearest: Well ._... 0 Foundation ......�fj���,. Property Line .... ...... <br /> SEEPAGE PIT { Depth ..eZ;r-t`. Diameter �.21IMumber _.__.__..�............. Rock Filled Yes 0"INO <br /> Water Table Depth .............. ......................Rock Size .-.f_�._.�+'-3---•--- <br /> Distance to nearest: Well .... .............foundation .....`P.. rProp. Line ...-, ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit` ............................................ Date __................................ <br /> } <br /> SepticTank (Specify Requirements) --•------------•------------- .............-................................................................................................ <br /> Disposal Field (Specify Requirements) ................... --•--•••..........................................................•---.._..-------•---------........_...... <br /> --••------------------------------------------------------ --------------------------------------------------.............•.............................---.....................I................. <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 San Joaquin Local Health:District. Home owner or Ilce <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 Califprnia." <br /> Signed --- ---------------- - --...--- - - --------- �......-•------ Owner ,-- <br /> -• ------ --- --- - -- ---------------------- <br /> By <br /> ..... ............... ---------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- --... -- ----------------------------------------------- DATE7. .. ..... .. ..................... <br /> BUILDING PERMIT ISSUED ----...--- -----------------------•---------------......_DATE ........................................ <br /> ... <br /> ADDITIONAL COMMENTS ..-..-----•-------------•--..__.._...-----...-------- ..------ ---- <br /> ---•- -• --------- • --------- ....................... <br /> ---------------------------- --------------------.------------- ,-.... ------------------------------••--- -•- ------- ............................................ <br /> ----------------------------•-••.... --------------------------------..-_............................................................................................__......_._._....._....... <br /> ----•------------•--------------•-•-------------- ...... <br /> - ---• ..._.......__ ........ <br /> Final Inspection by: .. _... . Gr - -------------•-• ..—1-1 <br /> .._ �! .��.-..__..---------- <br /> EI 13 22t 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 3M <br /> a <br /> r <br />