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FORZFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- <br /> 4 <br /> Permit No: <br /> iComplete in Triplicint ) <br /> ------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San oaquin 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 ---------- .`g` � �_C/ - ►* 4'. __ '� Cf' -_CENSUS TRACT �`L4�`........ <br /> Owner's Name -------- / -`---------------•--------------------------- --------------------.Phone <br /> Address -------------------------------------------------------------------------------------------- ---------• City ---------------------------------------------------------------------------- <br /> Contractor's Name -- --- ,4swtl.+wo 4 4 /Q License # Phone <br /> Installation will serve: Residencepartment 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'Er 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if pub1lic sewer is available within 200 feet,) h <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-------------------y---------------------------- Liquid Depth -_-_-----------------.----- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ----------------.----- <br /> li <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- 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 to nearest: Well ------------------------ Foundation -------------- --------- Property Line -------.-----------_---- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------- Rock Filled Yes ❑ No 0 <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) ----------------------------------------------------------- -----------------------•---� <br /> Disposal Field (S ecify Requirements) ------- �- -o :------ -----4�;- - ---sir---- ----------------------- <br /> r�-------------------------------------------------------- --------------------------------------------------------_------------------ <br /> ----------------------------------------------------- - ------------------------------ - <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 become subject to Workman's Compensation laws of California." <br /> Signed ----------------------- --- ------------------ ---------------------------------------. Owner <br /> By ------------------------------- - ---------- -Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------- - - -------------------- ------------ ------------------ DATE " - .�( -��*-*--------- <br /> BUILDING PERMIT ISSUED -------------- --------=--------------DATE ------------- ------------------ <br /> ADDITIONALCOMMENTS --------------------------- - - --------------------------------------------------------------------------------------- <br /> ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------- _ <br /> Final Inspection by: -------------- - ---- - - --1 l -ar__1_ � <br /> ----Date -_ _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 , 1-'68 Rev. 5M <br />