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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No. <br /> (Complete in Triplicate) ---- <br /> This Permit Expires 1 Year From Date Issued bate Issued <br /> ------------------------------------ <br /> ______-__________ _�'.r}--- ----.- <br /> Application is hereby made to the Son 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 549 and existing Rules and Regulations: <br /> _�'� <br /> JOB ADDRESS/LOC N - CENSUS TRACT -- --------_---. <br /> Owner's Name ` hone <br /> ! -- <br /> Address -- ----- d------- --- ----- <br /> --- City - _C_1— <br /> Name --- -- -------G ' -- •----.License # �� '�' Phone <br /> t <br /> Installation will serve: Residence ❑ Apartment HoArg Commercial ❑Trailer Court ;❑ <br /> 3 Motel ❑ Other . <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size --.-------------------------_------.--..---. <br /> Water Supply: Public System and name ------------------------------------- -------------------- ------------------------------------------------Private-� �h1 <br /> Character of soil toga depth of 3 feet: Sand'❑ Slit❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Qq <br /> Hardpan ❑ Adobe F] 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 [ j SEPTIC TANK [ ] Size----------------------=-------------------------- Liquid Depth -------------------------- <br /> Capacity ---------- -------- Type -------------------- 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 A---.-.--- Type Filter Material --------------------Depth Filter Material --------------------------------_---_.--_-.- l <br /> 1 <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ <br /> SEEPAGE <br /> ----------------- ---.SEEPAGE PIT [ ] Depth ---- --------------- Diameter ---------------- Number --------:-: ,-------- Rock Filled Yes ❑ No '❑ <br /> yy <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ;----.----..------- Prop. Line --------..------------ <br /> 1 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------- <br /> Septic Tank (Specify Requirements) ---------- - <br /> - --------------------------------------- <br /> so] Fiel (Specify Requireme ---- ------ - c� ------------------ - <br /> f <br /> - ------- -- --- ------- ------LZj---- ---- ----------- --- - Fd i '✓` <br /> ------ -- - ------�------.----- - - --------- -------------------------------------------------------------- <br /> ^' (Draw existing and required a ition on reverse'side) <br /> 1 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 Ucen- <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 subject orkman's Compensation laws of California." <br /> Signed -------------------- ----- -- -- - Owner <br /> BY --- ----------------------- ----------- ------ -f-- ................. <br /> . -- ---- Tit1e�Q <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------- ----------------------------- DATE ? -----------•� <br /> -- <br /> -- <br /> -------------- <br /> -- -------------------------------- <br /> BUILDING PERMIT ISSUED ----------- ------ ---- ---------------------------------------- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------- ------------------------- ---------------------­­--------- <br /> I------------------------------------ ------------------------------------------- ----------------------- <br /> --- --------------------------- --------------------------------------------- --------------------------------------------------------------------------------------------------------------- <br /> -------- D <br /> b <br /> -------------- ------- <br /> Final <br /> Ins ection by.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />