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M1 <br /> � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------- (Complete in Triplicate) Permit No. . ----------� <br /> --------------- - ---------- --------------------------- <br /> --- ---------- <br /> --------------------------______________ ____________________---------------- This Permit Expires 1 Year From Date Issued <br /> 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 /> 11'' = l ,Q - -------------------------- <br /> - <br /> �`- ----------- <br /> JOB ADDRESS/LOC ONI .__ ._/_77--,----- ---� L/ ---- � - - ---------------CENSUS TRACT ---- ----- <br /> Owner's Name ------ ---------------- -------------------Phone ••-------- <br /> --- ---- <br /> i i /� <br /> Address ------------- ! ----a2_sq- ---- <br /> - �---- -7----------------� -------------- �-- ------• City - -- --------------------------- <br /> Contractor's <br /> - , <br /> Contractor's Name --- --- ---- - ------ ------ ------------ -,� _ License # _ _Y Phone -----------:-------------_-_-- <br /> Installation will serve: Residence partment 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 Silt❑ Clay ❑ Peat 0, 4Sondy 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 public sewer-is--.available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ J Size_____________________—.— ___.___________ Liquid .Depth ----------------._______._ <br /> i Capacity -------------------- Type -------------------- Material------------------ --- No. Compartments ------ ----------= <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 /> i <br /> Distance to nearest: Well ________________________ Foundation _.------------------------ Property Line ________________._..._._ <br /> SEEPAGE PIT [ ) Depth ___I-________._ ___ Diameter ________f_______ Number _-----------_--------------- Rock Filled Yes ElNo ,0 <br /> i <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) __________________________________ _______________ _ <br /> Disposal Field (Specify Requirements) ---------&C_"_ <br /> j ,S X f6 ..5' � <br /> i u`- .�� -------------------------------------------------------- <br /> ---- ---------- -------------- ------ ------,----- --------------- <br /> 4 <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 Son 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: r <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 /> --------------- <br /> BY - ------------ ---------------------------------- Title _ ._. <br /> . (If other than owner)� <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - --------------------- ----------------- ------ <br /> DATE ---------------------- <br /> BUILDING PERMIT ISSUED -------------------------------- ------------------------DATE ------------------------------- <br /> ADDITIONALCOMMENTS ------------=-------------------------------------------------------------- ---------- ---- ---------------------------------------------------------- ------ <br /> E <br /> } <br /> -------------------------------------------- - - -- - ----------+--- <br /> Final Inspection by -- -- ----------------'---------------------------------------------_._--- -- _ -• --- - - <br /> Date <br /> : ------ ---- - ---- - ---- ------ - - --�- - --- ----------------- - ---- -- ------ - - -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />