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x;F6R OFFICE USE- <br /> -?' APPLICATION FOR SANITATION PERMIT S <br /> r ----- f <br /> - --- -------------------- Permit No. --------�- -- - <br /> _ (Complete in Triplicate) � - <br /> --------------------------------------------------------- This Permit Expires 1 Year From bete Issued Date Issued _���Q�507 <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 incompliancewith County Ordinance No. 549 and existing Rules and Regulations: <br /> tr <br /> �'7 ------------------------- ----- - -------CENSUS TRACT -------------------------- <br /> JOB AQDRESS/LOCA ION ._____ ____ __c�_�/ --- <br /> - Phone ------------------------------------ <br /> Owner's Name - --- ----- <br /> - -- - -- - -.�.�-- - ---------------------------------�•------ - ----- ----- - ---- ---- <br /> Address _- - - r <br /> g /r = City �----- - -- <br /> - <br /> Contractor's Name ________. -------- __________.License #��.�-z�2—Phone <br /> ----- y -- - <br /> Installation will serve: Residence DJ-Ara-rtment House❑ Commercial MTrailer Court ;❑ <br /> Motel ❑Other ------------------------------•--- --------- <br /> Number of living units:----.------ Number of b dro rps ______Garb ge Grin er ____ Lot Size _.,�_---X--- -.0. .............. <br /> Water Supply: Public System and name =___ ____ 4�!- _ �_______________ ______ Private <br /> Pp Y Y ! •---- ---------------- ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> { <br /> Hardpan ❑ Adobeill Material _„rtl _ If yes, type ____________________________ <br /> (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.l <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK[ ] Size------------------------------------------------ Liquid Depth --.___-------------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well __________________________________Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------ Length of each line---------------------------- Total Length ______._- <br /> `D' Box ------------ Type Filter Material ____________________Depth Filter Material ________________-_ <br /> Distance to nearest: Well _______________________ Foundation ---- _-------- Property line _______--____---__-.._-_ <br /> SEEPAGE PIT [ ] Depth __________________ Diameter _________y_____i Number _______________________ __ Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size -------------____....... <br /> .... <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------__.---- <br /> REPAIR/ADDITION{Prey. Sanitation Permit# _________________________________ __________ Date ----------.___.._.,.__..__.-______) <br /> Septic Tank (Specify Requirements) --------------------------- ------- --------------;----- -------------------------------- <br /> Disposal Field (Specify Requirements) ---------.. z_'�------ (/'l- __` - , <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------ <br /> ---- ------- --------- --------------------------- ------ ----m--------------------------------------------------------------------------------------------- <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 haws, 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 subject to Workman's Compensation laws of California." <br /> Signed ------------------- ----- -----— Owner <br /> By --------------------- - ------- -------------------------------- Title _� � "� <br /> -------------------------------------------------- <br /> (If er than owner) <br /> ,,! FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---e--d---- f ----------------------------------------------- DATE AP=-k9------- <br /> BUILDING PERMIT ISSUED ------------------------ --------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- --- <br /> ------------------------------------------ ------- -- - - -- -- - - - - - - - - - - <br /> - <br /> Final Inspection b Date __ y" <br /> ------ -- - -- - -------------- <br /> p Y d � - e ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'bl3 Rev. 5M y <br />