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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- P __.7_�_��_G <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 per 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 /> • R <br /> ADDRESS/LOCATION ._/ '� '__ _-_- .- e �2 ��-- lr ENSUS TRACT __------------_----------- <br /> JOB <br /> ot- <br /> 's Name -, -------- ---- --- ------------Phone ------------------------------------ <br /> Owner <br /> Address ---------------- <br /> Contractor's <br /> -------------- � © = J _-.. Cit ----------------- <br /> Y _ <br /> Contractor's Name ------------------------------ ------ ----- -- - ---- _........License # �_--- Phone ----------------------- <br /> Installation will serve: Residence Apartment Hou e,❑ Comm tial ❑Trailer Court ',❑ <br /> Motel ❑Other - <br /> Number of living units_____________ Number of bedroomsGarbage Grind__.___ 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�y 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 public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ]- -- .- _�; Size------------------------------------------------ Liquid Depth ----------------.---,----- <br /> Capacity --- - Type -------------------- Material---------------------- No. Compartments -------_---_---- <br /> Distance <br /> ------_---_ --Distance to nearest: Well '--:---------------------------------Foundation ---------------------- Prop. Line _-___________:__-....- <br /> LEACHING LINE [ ] No. of Lines ______.__._____________ .Length of, each line------ --------------------- Total Length ---------------------------- <br /> n � <br /> 'D' Box ------ Type Filter Material ....................Depth Filter Material -------------------------------------------- <br /> Distance <br /> --- ----.--_--____-___________--__---___.-Distance to nearest: Well ____._i_________________ Foundation ------ ------- Property Line ------------------------ ' <br /> SEEPAGE PIT [ ] Depth __ �""�_ Diameter: _____f___:_____ Numbe; _.__._____________________ Rock Filled Yes E] No ,0 <br /> Water Table-Depth ----------------=----------=-----------------..Rock Size -------------------------------- <br /> y <br /> Distance to nearest: Well --------_--------------------------------Foundation - ------------------ Prop. Line ...-------------__-_-• <br /> REPAIRJADDITION(Prev. Sanitation Permit# -•------------- ------------ ----------------- Date ----------------------------------] <br /> Septic Tank (Specify Requirements).------------------------- . ----- -------------------- ---------- -------------------- ----------------- -------------------- <br /> Di I Field (Specify Requirements) ��sr a <br /> ------------------------------------------------- - - - ---------------- <br /> L ------------------------------------------------------------------------------------------- <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 Son Joaquin Local Health District. Home owner or licen- <br /> sed agerits 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 ----------------- --- 2 ------------------------ -----. Owner <br /> --- - - -- --- - - <br /> BY ---- -_----- --- -- --- --- --------------- ;title __ C� -d`l ----------- <br /> t (If other than owner) <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -- <br /> - --- DATE . <br /> BUILDING PERMIT ISSUED ---------------------------------- ------------------------------------------------------------DATE - ------------------------------ <br /> ADDITIONALCOMMENTS ----------------------------- ---- ----------------------------------------------- -------------------------- ----- ---- -------- --------------------------- <br /> ------------- ------------ ------ --------- - - -------- ----- --------------------------------------------------------------------------- --------------- -------------------------------------- <br /> ------------------------------ -- -- �- ----- - -7 ---_------- <br /> Final Inspection by: _ --------- ----------------------------------------------Date -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />