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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> Permit No: - -- //_. <br /> a (Complete in Triplicate) <br /> -----------------------------•---------------- <br /> ii --- This Permit Expires ] Year From Date Issued 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/LOCATIO -- ��? `' -- `--- ----------CENSUS TRACT -------- <br /> Owner's Name t G`�' c --------------= ------ ---,----Phonef7-/ -- 1 <br /> Address --------- ----- ------ ----- City -`�"�' j <br /> Contractor's Name -------- -- --- - -----------------------------License #/0--f-/,-------- Phone -y6 -- Yc� 7 <br /> Installation will serve: Residence ❑Apartment House�0 Commercial :❑Trailer Court i❑ <br /> jj Motel ❑Other ---------------------------------------- I <br /> Number of living units:_-----!---- Number of bedrooms ---3-----Ga�bage Grinder ---------- Lot Size ____�1_____�--__- ---------- <br /> Water Supply: Public System and name --------------------------------••-- --------------------------------- ---------- ------- Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Laam , <br /> Hardpan ❑ Adobe '❑ Fill Material ________ If yes, type ________________ ------- <br /> (Plot <br /> - ---(Plot plan, showing size of lot, location of system in relation :to wells, buildings, etc. must.be placed on reverse side.) <br /> NEWkINSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![ I Size------------------------------------------------ Liquid Depth -----------.________,____- <br /> - Type ______________ ;Material________---_- No. Com artments ______-_________------ <br /> •.[ ��r �` Capacity ------------- ->� Yp ------ - --- p } <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop; Line ------------.:....:._. <br /> t <br /> BEACHING LINE [ ] No, of Lines ---------------------- ''Length of each line------ --_------------------ Total Length ,----------•----------____-. <br /> f t, <br /> ` 'D' Box --------------�1ype Filter Material ------______ _______Depth Filter Material <br /> _ r _ .._ _- _. <br /> +err.—_.....—- <br /> pistance to nearest�Well� ` Foundation Line ------------------------ <br /> SE 3E <br /> _______________________SEEPAGE PIT [ ] Depth Dia+neter --------------------- Number ------------- := Rock Filled Yes ❑ No i❑ <br /> 'i nWater Table Depth' �------------1----------------------------------Rock Size,.-,-'.. - ----------------- ` <br /> � -Distanceto-nearest: Wel l_______------_---------------------------Foundation -------� Prop) Line ----------........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---- ----------'J------- -----} <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------- --------------------- --------------- --------------------------- <br /> { <br /> Disposal Field (Specify Requirements[ ? �, --- ---- ---------/------ y h <br /> aC,X ' <br /> ---- <br /> 1 <br /> ----------------------------------=------------------------' ------ ------- ------------------------------------------:-------------------------- -- --------------- <br /> -(Draw existing and requi red addition onon 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: - --�-*— i E <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 Cal., -.tet <br /> -Signed ----- ---------- ------ Owner <br /> ---------------- -------- ` <br /> %EKY----------- ---- r --------------l---�,I itle <br /> - <br /> (If other t owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED•BY-'----------- - ----�-_ _ _... .....___. .._.__ ..DATE ------------------------------------------- <br /> -- <br /> ------------------- - <br /> ----- - ---------------------- <br /> BUILDING PERMIT ISSUED ------------------ -------------------DATE ------------------------------------------- <br /> -- - -- ---- <br /> ADDITIONAL COMMENTS,---t.�, <br /> ---------------- -------- ------------------------------------ ---------------------------------------------------------- -------------- <br /> i ` ' f <br /> ------------------------------------------------------- ----------------------- ---- c_-------- __________________:__________________________________--____----____________.____--___.________--___-__ <br /> _______________________ ____ ___--r__ __—______�.__•_�_ - -- ___________—___--_______._____-_—----—--—-______—___._______________.________-_------------------------- <br /> ------------- <br /> --------------------------——"_____ --—__— ___ <br /> Final Inspection b --------------------------------------------------------------- to ---- <br /> P Y ------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />