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: FOR OFFICE'USE: , <br /> APPLICATION FOR SANITATION PERMIT <br /> �.... ._ <br /> (Complete in Triplicate) Permit No. . ... ............. <br /> Date w... <br /> -----................................:--•--...---........._ to Issued.-.�� <br /> ........__ `.. t �i�hi:permit Expires 1 Year from Date Issued " . <br /> Application is hereby made tat a Sart Joaquin Local Health District for a permit to construct and Install the work herein <br /> described. This application is made in comp ' nce with ty Ordinance No. 549 and existing Rules and Regulations: <br /> -. :._ „ <br /> JOB ADDRESS/LOCATI x._...... ................ . .......Q_. ..... ........... CENSUS TRACT ........................,. <br /> Owner's Name ....fir_ <br /> . . - ------- ---- o <br /> . . . .. ........... <br /> Addr <br /> .......Phone ....... <br /> ess <br /> City .................. ---- --•-- <br /> . 1 - ....License #Contractor's Name . .. Phone .....:..... . ......... <br /> installation will serve: Residence Apartment House{] Commercial ❑Trailer Court <br /> f Motel ❑Other......./--........................... <br /> ..... <br /> Number of living units............. Number of (bedrooms _7.......Garbage Grinder ............ Lot Size .............................:.............. <br /> Water Supply: Public System and name --------------- ........................._........••---•-----•-•--......------.................. ..............Private Qf <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay 0 Peat❑ Sandy Loam {Clay Loam ❑ <br /> Hardpan❑ Adobe❑ Fill Material --._--- .... If yes,type <br /> . .... ...... <br /> (Plot plan, showing size of lot, location of system in relation to wefts, 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 l°,] Size <br /> ............=�--- ..... Liquid Depth ............ .....:.... <br /> Capacity-------------------- Type -------------------- Material.........--------..... No. Compartments ...................... <br /> Distance. to nearest: Wel! ....................................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ j No. of Lines ------------ ---------- Length of each line--------------:------------- Total Length ..............._........... <br /> 'D' Box -----------. Type Filter Material .................:..Depth Filter Material ..._.._. J <br /> Distance to nearest: Well -----------------------. Foundatio. Property Line N <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 /> :I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........-----------------------•--•.--...... Date­__.....................-----.--..) <br /> Septic Tank (Specify Requirements) _-----------•- .../.-----p- .---....•-.--- .......= ...............•------------ � <br /> j Disposal Field (Specify Requirements) ..: -- . 1' -- _ ..._..r_.._.. �___._.- <br /> - . <br /> - ---------------•------- --------. ----- ---- <br /> I (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, 'end Rules and Regulations of the San Joaquin local Health:District. Hayne 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, l shall not employ any person in such manner <br /> G as to become subject to Workman's Compensation laws of California." <br /> } Signed ---- --------------------------------------- -- Owner <br /> By -•-. ----.-_---------- •---------------- -•--... ------- •-• �xitle ----. ....... <br /> .- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _-- DATEI_! -.'� .."7. _..._._.._: <br /> --- •--•-------------------------------- <br /> -._ <br /> r BUILDING PERMIT ISSUED ----------=----------------------•--•- ••--------------•----------------------------------------------------------------- ---DATE ...........................................ADDITIONAL COMMENTS ----- ....I.....---------------------...... <br /> ....- <br /> .-----.. ------•---------- --------------- -------------------- ----------------------------------- --"-- ---- <br /> - --------- -'----,- <br /> ------- <br /> --------------- ------- <br /> -------------------------------------------- ------------------------------------------------------- -•-------....---- ............................ --- ....---............. <br /> ----------------------•--- .... <br /> final Inspection by: Date <br /> EH 13 24 1•-68 Rev. 5M � SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />