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FOR OFF CE USE: <br /> •� APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _ __,_ . _ __ <br /> ---------=------ --- <br /> This Permit Expires 1 Year From Date Issued Date Issued !6f <br /> Application <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/LOCATION °....._____ - _ ------CENSUS TRACT} _ -------._. <br /> -- <br /> Owner's Name ----- e/-------------------------------------------------------------------------- ----- Phone <br /> 4�Address ------------------ -- o�i <br /> - __- ---------------------------- <br /> - city <br /> Contractor's Name ? <br /> - License # - Phone .S_ <br /> ................... <br /> will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units:.---l------ 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'�ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ___________________--_____ <br /> (Pilot 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 seepa a pit permitted if public sewer is available within 200 feet,) <br /> wJ 7 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ Size-- :�T� ___._______,_ Liquid Depth -__z'_ '_._._._ ------ <br /> Capacity " ' '.__ Typi�� Material� '�° ___ No. Compartments _12_1............. <br /> Distance to nearest: Well __ _y:__________________Foundation _Z.P_--_______-___ Prop. Line ._��-�............. <br /> LEACHING LINE M-- No. of Lines ___, _____________ Length of each line-----. s/�,_ -____-__-___ Total Length ___: _ .......... <br /> 'D' Box Type Filter Material ` ____________Depth Filter Material -----/;1-7_........................... <br /> Distance to nearest: Well _--J'6 ------------ Foundation __� _r---------- Property Line ___�;_,=_---____--_-___ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ______________ Number _________________________ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ----------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well _ ___.______-___________________Foundation __________________ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date __________________________________) <br /> Septic Tank (Specify Requirements) ----------------- ------------------------•- -------•-------•----------------- ---•---•-- <br /> Disposal Field (Specify Requirements) ----------------------------------------------------------------------------------------------------- ---------------.--------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -•---------- <br /> -------------------------------- ----------------- --------------------I---------------------------------------------------- ---------------------------------------- <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 <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'-- blect W 's Co ation la of California." <br /> cf�/j <br /> Signed =� �If - �T%` `' Owner <br /> BY ----------------------------------------------------------------------------------------------------- Title ---------------------------------------- ---------------------------- <br /> (If other than owner) <br /> FOR PMT ENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- DATE ' � <br /> ------------- <br /> - - -BUILDING PERMIT ISSUED ----------------- -- ----------- ---------------------------------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------- - ----- ---------=------- <br /> z. <br /> Final Inspection by: -------------- - --�_ ��-- -------------------------------------------------------------------------------.____.Date ---- ----•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />