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JFOR OFFICE USE: <br /> ..• APPLICATION FOR SANITATION PERMIT <br /> � <br /> z� � a � <br /> (Complete in Triplicate) Permit No. __ __ _____._.____ <br /> ---- --- .- --------- ---------------------- <br /> � _ � <br /> Date Issued 2 <br /> ---------------------- ----------- ------------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the ISan Joaquin Local Health District for a per 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 J > '� ---------------- -----------------------------CENSUS TRACT -------------------------- <br /> Owner's Name --- ----------------------------------------------------------w-------------------Phone ------ <br /> Address .-- --------------------•------------------------------------------------- City. ------------------------------------ ------- <br /> Contractor's <br /> ------------------------------- •- <br /> Contractor's Name --- e-------- ------------------------License ---- Phone <br /> Installation will serve: Residence ZApartment House❑ Commercial :❑Trailer Court ;❑ ' <br /> IMotel ❑ Other -------------------------------------------- <br /> Number of livingunits.----/______ Number of bedrooms __ ---_-_Garbo a Grinder _ a._ Lot Size _ X--��------------------- <br /> I oc 9 <br /> Water Supply: Public System and name ----------------------------------------------------------------------•---------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> IHardpan ❑ AdobejX 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 /> l NEW INSTALLATION: (No septic:tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> G'. <br /> PACKAGE TREATMENT SEPTIC TANK_ --------- Liquid Depth _&!____--------------- <br /> . <br /> Capacityl�& _ + Typ Material_ No. Compartments <br /> Distance to nearest: Well -------------------Foundation _. -------- Prop. Line ___5t--_`:__----__ <br /> LEACHING LINE [ No. of Liries /----------------- Length of each line----- ---------- Total Length ,_,1� _ ----------- <br /> D' Box Ia----- Type Filter Material j0_ ____Depth Filter Material _ _ ________________________________ <br /> Distance to nearest: Well - Foundation ,149___ ___________ Property Line __5 - <br /> SEEPAGE PIT fj Depth -------- Diameter __3,6'_,0001_ Number ------/-_--x------------- Rock Filled Yes No 0 <br /> Water Table Depth -500------------------------------------Rock <br /> ---------------------•------------Rock Size ���.fl� I-----------•--- -T <br /> Distance to nearest: Well ----------------------------Foundation -- --f._.____ Prop. Line ___ .�........_ <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -_______.______ ____________ Date __________________________________} <br /> SepticTank (Specify Requirements) -------- ------------- ----------------------------------------------------------•--------------------------------------------------------- <br /> DisposalField {Specify Require,ments) ---------•- ------------------•-------------------------------------------------------------------------------------- --------------- <br /> -------------------------------------------------------�------------------------------------------------------------------------------------ - ---------- <br /> =---------- ------------ <br /> ------------------------------------------------------=--------------------------------------------------------------------------------------------------------------------------------------------------- <br /> .i (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 "I certify that in th performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> f as to become su ecAhn <br /> an' Compensation laws of California." <br /> Signed -- --- --- ------- /----------------------------------------------- Owner <br /> BY �l - -------------------------------------------- Title <br /> --------------------------------------------------- <br /> {lf othner)l <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - ------------------------------------------------------------------. DATE �7 _-'-------------------- <br /> BUILDING PERMIT ISSUED -------------------------- ---------------------------- --------------DATE --------- ----------------------------- <br /> ADDITIONAL COMMENTS ----------- I------------------------------------------------------------------- ------------------------------------------------- ---------------•----------- <br />+ r <br /> 1 <br /> -- ---- --------- - . -r- <br /> - -------------------------------- <br /> "2 <br /> -------------- <br /> -------------'--_ <br /> ----- <br /> -------------------------------DateFinal Inspection by SAN JOAQUIN CAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />