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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --- <br /> (Complete in Triplicate) Permit No. <br /> -------------------- ---------- <br /> Date Issued <br /> ---_---------------------------------------------------- This Permit Expires 1 Year From 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 Coun y Ordinance No. 549 a d existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._�- _- ----li' -- - - -- -- -- - ------ �T � CENSUS TRACT --------------.--------P-- <br /> Owner's Name --.d7Y2 •- _------------------------------------------------ Phone <br /> Address . -- �------ ------------- ---- -------•--. City -. e�.- ------------------------------------------------ <br /> Contractor's Nam , 4' <br /> ---------------------License #�� .�� Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court <br /> 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 /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) f� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) W <br /> PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------- ----------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ----------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --.--------__-_-.-_-._ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line----------------- Total Length ---------------------------- <br /> 'D' <br /> --- .----_--..-.._.-_'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <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 /> Septic Tank (Specify Requirements) -------- ------------------ ------------------ ---------------------------------- j <br /> Disposal Field (Specify Requirements) -- -------- <br /> -------- --------------- f `�----- --------------- -�-- -- --- ------------------------ ------------------------ <br /> --------------------- ----------------------------,--------------------------------------------------------- ----- ------------ ---------------- <br /> (Dr aw 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 /> "1 certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - 1 --------- <br /> E"7re—r <br /> Y - - <br /> Z� j <br /> ----------------------- <br /> --------------- <br /> Title <br /> '(If other than owne <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -. - - -----. DATE ------------------- <br /> BUILDING <br /> - - - - -------------- --------------------------- ----------------- <br /> BUILDING PERMIT ISSUED ------ ------ -------------------------------------------------------------------------------------------DATE ------ ------------------------------------ <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------- ------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----( <br /> -V...... <br /> ------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------- -------------- ------- <br /> Final Inspection by - Dated- r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />