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i <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - - - - - -- -- - ----------- Permit No. -/--- -- <br /> (Complete in Triplicate) <br /> ------=--=----------------------------------------------- <br /> _________________________________________________________ This Permit Expires 11 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/LO TION _//� 'Z' �------- �•p — CENSUS TRACT <br /> Owner's Nam - - ------------ -- ----- -- �------ ------- --------a__ PhoneAddress U�-.117 ----------------------------- <br /> t� t-- - --- r --- -'"- -. - City ` <br /> Contractor's Name ---------- - - -- -- License # _/? _y Phone ---------------------------_._ <br /> Installation will serve: — --Residence.. -Apartment House,❑-Commercial-[=]Trailer Court-;❑--�-��-�-- <br /> Motel ❑ Other ------------ ---------------------------- <br /> I. , <br /> Number of living units:-----/----`Number of bedrooms ----__-__-Garbage Grinder ------------ Lot Size ----- .. <br /> Water Supply: Public System and name~------'----------------------------------------•------------------------•---•----------- -----------Private <br /> � P <br /> Character of soil to a depth of 3 feet: Sand'❑` Silt E] Clay E-1Peat E] Sandy Loam Clay Loam;❑ <br /> Hardpan ❑ Adobe-E] 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,) O <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ) Size_ 1_________ '- ------------------------- Liquid Depth --------.------------ <br /> Capacity <br /> ___________,_____ 5 <br /> Ca acit ` No. Compartments - --_-__- ------------ <br /> Distance <br /> -- 1 - <br /> P Y - ------------------ TYPe -------------------- Material-'-.------=---------- '- -•------- <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 [ j Depth -------------------- Diameter ________________ Number Et-_--.--------_-_---___ 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 /> SepticTank (Specify Requirements) ------- ----- -- -----------------------------------------------------------------------�--------------------------------------------- I <br /> ti � �.J <br /> Disposal Field (Specify Requirements) ____ __ __ _ �c�,�.�__ _ __ -----�E ..�----------- <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 R <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 rkman's Compensatio ws of California." <br /> Signed -------------------------- - -- ---- ----------. Owner <br /> BY ---------------------- '----------- ---------------- 'tie ----- -------------------------------- <br /> (Ifother than owner <br /> FOR DEPARTMEjNT' USE ONLY <br /> APPLICATION ACCEPTED BY - / --------------------------------------. DATE // y s <br /> BUILDING PERMIT ISSUED --------- --------- --------------- ------------ ----- DATE ------------------------------------------- <br /> ADDITIONAL <br /> ---------------- - <br /> ADDITIONALCOMMENTS ------------------ -------------------- ----------------------------------------- ----------------------------------- --------------------------- <br /> ----------- <br /> -------------------------------- <br /> --- ------------------------- -------- -------------- ---- ----------- - -- <br /> Final Inspection by: Date .. - ------------ 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M 0 <br />