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FOR OFFICE USE: q APPLICATION FOR SANITATION PERMIT <br /> ----- --------------- ---------------------------- Permit No. -----w_ <br /> i� (Complete in Triplicate) ' <br /> - -------- <br /> ------------------------------------------------ <br /> 1. This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made #o 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. 49 and existing Rules and Regulations: <br /> il_ � _�-----------------------------------------CENSUS TRACT _ --- . <br /> Owner's er 'S NaneLOCATlO -------------- ----------------------------------- <br /> -------------------------------- -------------------Phone ------------------------------------ <br /> Address ------'� T~� +� City <br /> Contractor's Name. --------------------------------------------------------------------License# ---------:-------------- Phone ---------------------- ------- <br /> Installation will serve: j Residence Apartment House❑ Commercial :❑Trailer Court <br /> I <br /> Motel F-1 Other <br /> -------------------------------------------- <br /> Number of livingunits:______ { <br /> ___ Number of bedrooms ____________Garbage Grinder ______-____ Lot Size _________________________________________ � <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------- -----------Private ❑ <br /> r: <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Gay ❑ Peat❑ Sandy Loom ❑ Clay Loam;❑ _j <br /> !� Hardpan ❑ Adobe❑ Fill Material ------------ If yes,type ____________________________ <br /> (Plot plan, showing size ofMot, 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,) 4 <br /> I <br /> PACKAGE TREATMENT [ ;j SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ---------------------.----- I <br /> II <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- _-------- <br /> LEACHING LINE [ j No.{lof Lines ------------------------ Length of each line---------------------------. Total Length ____---.___._______-_-_.__ <br /> �I <br /> 'D' Box ___________ Type Filter Material ____________________Depth Filter Material _______________ <br /> q <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _____________ ........ <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------ ------- a <br /> Distance to nearest: Well ----------------------------------- ----Foundation -------------------- Prop. Line --------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------`-------------------------- Date -_-------------.------------------) <br /> fi �. <br /> P y q <br /> Septic Tank (Specify Requirements) __________ -- - <br /> Disposal Field (S ecify Requirements) __ �---- - -- --=--- '---- / f' <br /> _ iI ---------- <br /> ----------------- - - ._ !*-7^- � <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 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 I Wort's Com sati.on laws of California/ <br /> Signed ecome�s b'ect Wor r - --------------------------------------- Owner <br /> Ale <br /> By ------ ---------------------------------�� --------------- -------------------------- ----Title - <br /> (If other than owner) <br /> IiAl -FOR D TME4 USE ONLY <br /> APPLICATION ACCEPTED BY ---o�z "t-' ------------------------------------------------ DATE/nA. -- -- ---- ---------•--------- <br /> BUILDING PERMIT ISSUED - i---------✓--- !r -- -------------------------------------=----------- DATE <br /> --------------------------------------------- ----------------------------------------- -- - - ---------------------- -------------------------------------------------- ---------------•----------- <br /> ADDITIONAL COMMENTS _ <br /> --------------------------------- - ----------- <br /> ----------------------------------------------------------- k <br /> ------------------------------------------ - Ii- ------------- F <br /> -------------------------------- = ----------------------------------------------------------------------------------- <br /> Final Inspection by: ": - ,, - -----------------------------------------------------------------------------Date, ----------- ° ------------------- <br /> SAN <br /> --- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �I I <br /> E. H. 9 1-'68 Rev. 5M. �� <br />