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-"FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �G t <br />,.. ..._.._._.............. .................... Permit No. .. ` ..,__...... <br /> (Complete in Triplicate) <br />_................................................... <br /> Date Issued <br /> This Permit Expires 1 Year From pate Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made lin compliance with County Ordinance No. <br /> � and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..�� v�..l.._. CENSUS TRACT <br /> Owner's Name _. .. ,....... :.......-••--.........Phone ................................... <br /> . . <br /> ......' <br /> cityAddress --------------•---................_.....-----...................... <br /> Contractor's Name ..license # ........................ Phone ...............:............... <br /> ................. <br /> Installation will serve: Residence)Apartment Hqusef❑ Commercial ❑Trailer Court 0 <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❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material ......... <br /> If yes, type ......._....._._..--•._-__-- <br /> (Plot pian, 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 /> PACKAGI -TREATMENT [ ] SEPTIC TANK i ] . Size..............................•................. liquid Depth ........................•• <br /> CapacityType ..... Material.-.................... No. Compartments ........._ ........... <br /> Distance to nearest: Well ------------- •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 ._.....--------- --------------------- <br /> Distance to nearest: <br /> Well ........................ Foundation ...... .............. Property Line ........................ <br /> 4 <br /> SEEPAGE PIT [ ] Depth ... -- Diameter ................ Number .-___---------- ------ Rock Filled Yes ❑ No (:3 <br /> Water Table Depth ---••................•----..Rock Size ........-------. -----• ------- <br /> Distance to nearest: Well _.....Foundation .................... Prop. Line ...................... r <br /> REPAIR/ADDITION l v. Sanitation Permit# ........•............... Date ........................_._-..--.-) <br /> y Requirements) . •--•..................... ........ <br /> . ----- ------- - <br /> Disposal Field (Specify Req irements) ...... .... .......•-••-- '•'" �r .� <br /> .! � �.� 5 1 <br /> w�.. -a�--=...--- .__. .. '7�.... �... � <br /> •--...................•--------- <br /> {Draw existing and required addition on reverse sides <br /> i <br /> I hereby certify that 1 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 �cen- <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 comes get t Wo an' �*Mnsation laws of California." <br /> Signed _r ... _.... -•--------•. <br /> Owner <br /> ............ ....................... Title ................._................................... .............. <br /> l <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .._ DATE ...__.. ..... .......... .. ----••--• <br /> BUILDING PERMIT ISSUED _.._. .. ••-........DATE ...__................................._..... <br /> ADDITIONALCOMMENTS ................. ---.--------------------------------................:.............-------------- <br /> -.-......... <br /> ........................... ----_... --- .------ <br /> �. � ..... <br /> Final Inspection by: Date ....... ...........�".._._._. ._.._.._.._. <br /> _ ,SAN.JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 7/72 3 M <br />