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FOR OFFICE USE APPLICATION F©R SANITATION PERMIT <br /> Permit No: <br /> I ---- --------------------------- -- :- -=:-.I`:---- (Complete in Triplicate) <br /> Date Issued <br /> --------- ----------------------------------- III <br /> --�}. -�_ �' <br /> This Permit Expires 1 Year From Date Issued <br /> I� <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 applicati6k is made in compliance with County prdinance No. 549 and existing Rules and Regulations: <br /> i <br /> GG.uG{r. CENSUS TRACT�JOB ADDRESS/LOCATIOON -6! <br /> Owner's Name -------- -------- <br /> � -------- - ------------ -------------------------------------------------Phone ------- <br /> Address ------------------ -__'J__ - -- ------9 -- --- ----- City ------------------------------------------------- <br /> Contractor's Name ----------:11- ------- ------ �J-fT �----------------License # �UD,�/�----- Phone --- <br /> Installation will serve: Residence [Apartment House❑ Commercial []Trailer Court ;❑ <br /> \jMotel ❑Other ----- - <br /> Number of living units:-- ____-.Number of bedrooms --,,7------Garba_ge Grinder ------------ Lot Size -l-w----- --------------•---------- <br /> 1 Water Supply: Public Systl m and name ------------------------------------------------------------------------------------ -----------------.--------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loamy <br /> :1. 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 /> 11. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> I _ Liquid Depth <br /> PACKAGE TREATMENT �Capacity <br /> TANK' T e Size_ - _- <br /> {{ [ [ ]y <br /> s C� P y ---------------- - yP,` ,.. . -- Material-------------- Na. Compartments <br /> Distance to nearest: Well --"---------------------•---------Foundation ---------------------- Prop. Line ----------...:_,------ <br /> i ---- Total Len <br /> LEACHING LINE [ ] No. of Lines Length_.of,,.each„line:-:--------------- ----- Length ----------- ------------- <br /> I�. <br /> � -----------------Depth. Filter Material --------------------•------------•---------- <br /> iD' Box .____---.--- Type Filter Material �-- + <br /> Yp <br /> Distance to nearest: Well -----------------------`-,Foundation -- .------------------- Property Line --------------_.--.-.--- <br /> i it ,..- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------- ---------------- Rock Filled Yes ❑ No '❑ <br /> Water Table Depth -----------------------------------------------..Rock Size ----------------------- -------- <br /> Distance � - ---- ,,--..-Foundation ----------- p ... <br /> Distance to nearest: Wefil—r_-._---__---'---___.-- - -_----- Pro Line ------------------- <br /> 'i <br /> REPAIR/ADDITION[Prev. I-Sanitation Permit# ------------------------------:------------- Date ------------------------------ --- <br /> Septic Tank (Specify Requirements) ---- ---------------------------------- --------r--� _ ------------------------- <br /> ----- --------- <br /> --------- <br /> ----� �_ <br /> Disposal Field (Specifly;Requirements) -------------- -- O--- -------- ---------- <br /> ---------------------------------------------- ------------6 ----------------------- -- - <br /> ----------------------------------------------------------- ------------------------------- <br /> IIN: - ---------------------------------------------------------------------------------- <br /> --------- <br /> 4 (Draw.existing and required',addition on reverse side) <br /> �. r'- <br /> I hereby certify that I have prepared this dpplication ah-d-that the work will be done in accordance with San Joaquin <br /> County Ordinances, Statle[ Laws, and Rules and Regulaflons o'f rtlie-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 peemit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.” - - <br /> I . <br /> Signed ------------------------- �� -- - - -- - -- Owner <br /> `• � -------------- <br /> By - ------------ Title <br /> (If of hqn owner) <br /> t <br /> 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.--- - _- ` ------- <br /> --�-- -------------------- - ---------------------- _----._DATE _---------=---- -------•---------- - <br /> BUILDING PERMIT ISSUED --------------------------- --- --- - _ t=_:-DATE.= = -_ <br /> ADDITIONAL-COMMENT ------ ''_ = ----- ---------- .. ... - — - <br /> -------------------------------------------------------------------------------F-------------------;-------------------------------------------------------------- <br /> ;l------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------- <br /> ------------------------------------------ <br /> --- <br /> -_ - ____ _M;�;:i.-j---j-"------------------ ----- <br /> ------------------------1 <br /> - -- <br /> ------------------------------------------ <br /> Final Inspection by: -------II. & ---------------- ------------------- r---- ----------- Date <br /> '" . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5' <br />