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I <br /> FOR OFFICE USE: � <br /> APPLICATION FOR SANITATION PERMIT <br /> 4 (Complete in Triplicate) Permit No: <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 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 -----------------9t�----------------------•- -- CENSUS TRACT <br /> ------------ <br /> - <br /> Owner's Name -__. _ <br /> = ------------------------------------------- Phone <br /> Address --- ---- -------------- ------r---------- <br /> f <br /> Contractor's Name -- -cR. .- --- *c� ------------------- License #lff34P_ ---- Phone _----_------__-------------•-- <br /> Installation will serve: Residence ❑Apartment House,❑ Commercial :❑Trailer Court ❑ <br /> Motel ❑ Other -------- - ---------_----- <br /> Number of living units:-----A-- Number of bedrooms ___Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> i ' <br /> Water. Supply: Public System and name ------------ ---------------------------------------------------------------Private,` <br /> --------------------------- ----------------•---------------Private,` <br /> Characterofsoil to.a depth-df-3-fe;fi- -Sdnd`0' Silt❑ Clay 0 Peat Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan rt?5 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.) 0 NEW INSTALLATION: (No.septic,tank or:seepage pit.permitted if public sewer is available within 200 feet,) �N <br /> III PACKAGE TREATMENT { ] SEPTIC.TANK ]` . . Size----------------------------------- ------ Liquid Depth ---------------------.----• [,v� <br /> } Capacityi-- --- - -"'.: Type•--------Y = Material-------------------- No: Compartments ...................... -1 <br /> Distance to nearest:'Wall-------------------------=-------------Foundation ---------------------- Prop. Line ------------------------- <br /> LEACHING <br /> --------- :--------LEACHING LINE [ ) No, of Cines ___________ ____________ 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 _____-=___: ___ Nurriber'-----------------------------_ Rock Filled Yes E] No C]' Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> -------------------- -•----Distance to nearest: Well _______________________________________Foundation _-________________ - Prop. Line ____-._ ------- <br /> �Q <br /> i - . <br /> REPAIR/ADDITION(Prev. Sanitation'Permit# -------- ----------------------------------- Date __________________________________) <br /> 1 - <br /> 'Septic Tank (Speeify Requirernerits) -----------------.----- " , <br /> Disposal Field (Specify Requirements) _ -----+. <br /> ------------------------------- -- ----------------I------------------------ <br /> ----- ------------------------------------ ----- - ----------------- ----------------------- <br /> y� �' <br /> (Draw existing and re uired dition 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 /> i as to become subject'to Workman's!! Compensation laws of California," <br /> " Signed --- ---------------------------------=-- - -------- Owner e --- �- -- ' <br /> ---- ------- <br /> `u ' <br /> BY . -�-- Title ---- - ---------- ------- <br /> (If other than owner), <br /> FOR DEPARTMENT USE ONLY � <br /> APPLICATION ACCEPTED BY - ------ ---------- - - DATE <br /> BUILDING PERMIT ISSUED -- --- <br /> --- `- ---------------------------------------------------------------------------- -------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -------------;-(----------------------------------------------------------------- <br /> -------------------------------------------------- <br /> ------------------------------- <br /> ---- ---- ---- - -------/----------------------------- <br /> --- -------------------------- --------- -- - --------------------------------------------------------- <br /> ----------- 2-- <br /> ------------------------------------------ ---- <br /> _________________________________ _____ ---. __ _ _ _ _ __ _ _ <br /> Final Inspection bY: -`ii Dat <br /> --- --- -- - - - - - --- <br /> SAN JOAQUIN L AAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />