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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------z-------------- Permit No. <br /> --------------- <br /> (Complete in Triplicate} <br /> ---------_-----------__---------------- --------------- This Permit Expires 1 Year From Date Issued <br /> 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 /> 5, 'j��- <br /> ------- ------ CENSUS TRACT <br /> JOB ADDRESS/LOCA _�® -�--------------v�-r---- --- - -- -- - ---- <br /> Owner's Name --- ------ =------ -- -- --------- ----Phone---------------------------------- <br /> -------•---------------•-------- <br /> Address ��--��9- -�------ ----------� - -----�-------. City ---- -- ----------* - --------------- <br /> SifContractor's Name ----------- -�- - '-.License # �� - Phone --------------------- -------- <br /> Res idence a�rtment I-louse Commercial : Trailer Court ;❑ <br /> Installation will serve: s p ❑ ❑ <br /> FMotel ❑Other --L.1----------------------------- --------- <br /> Number of living units:__:__ ---- Number of bedrooms -_,_�?—_--Garbage Grinder ------------ Lot Size ------� <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private, <br /> Char—acter of soil to a depth of;3-'feet: -Sand❑ Silt❑ Clay ❑ Peat E] Sandy Loam X -Clay Loam ❑ <br /> 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public,sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] 'SEPT IC.TANK: _-.., `Size-----------------------•------------------------ Liquid Depth _-..------------------ _- <br /> .sem.. - . _�....[ ]_ - <br /> .. <br /> 1-1Copacity -------------------- Type ------ ------------- Material-.--------------- No. Compartments <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> ,,L•EACHING LINE [ ] No. of Lines ----------_____------------'Length of each line------------------- -------- Total Length :.----_.___.______--.-..-.-- <br /> J I 'D' Box -------- Type Filter Material --------------------Depth Filter Material -----------------------------.-------_--•- <br /> ! Distance to nearest: Well -----------_----____.-_ Foundation ------------------------ Property Line, _----_---..._-_-_--_-- <br /> SEEPAGE PIT [ Depth -- ----------------- Diameter ________________ Number .---_-- -------------------- Rock Filled Yes ❑ No <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 Re irements) --------- -- i ---- ---- <br /> ------ - -- -------------------------------- <br /> -------------------------------- ----- <br /> ---------- <br /> ----------------- -------------------------------------- ------------------------------------------------------------------- ----------------------------------------------------------------- ------- <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 mariner <br /> as to become subject to Workman' ensation laws of California." <br /> Signed ------------------------- -------- --- -- ---- ----- Owner <br /> By - ------------------------------- tle ..... <br /> . . <br /> (If other than owner) I <br /> - <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY cwt = --------------------------------------- <br /> DATE --- <br /> -------------- <br /> BUILDING PERMIT ISSUED ------- ----------------- -------------------------------------------------------------------------------DATE -------------•----------------------------. i <br /> ADDITIONAL COMMENTS ---------------------------------------------------------------•--•----------------------------------------=---------------------- <br /> , --------------------------- <br /> -;.- --------------------------------------------------------------------- <br /> --------------------------------------------------------------------------- -- -------_------ ------------------------------------- --- ------------------------ <br /> ----- <br /> ----------- <br /> Final Inspection by: ------ - +� Date _. <br /> SAN J QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />