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4 <br /> FOR OFFIC?USE: APPLICATION FOR SANITATION PERMIT <br /> - ------------------------------ ------------ ------ (Complete in Triplicate) Permit No. ---------------- <br /> ---- <br /> - <br /> -------------------------------------------------------- <br /> This Permit Expires 1 Year From bate Issued <br /> Date Issue -------------------- <br /> _ <br /> ------------------------ ------- --------------------- <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 /> JOBADDRESS/LOCATION .-- - --------------------------------------------------------- ---------------- -------- ---------------CENSUS TRACT ----- --------•----------- <br /> Owner's Name --- --- ---------- ----------------------------------------------------------------------- ----------------- -------------------Phone ------------------------------------ <br /> Cit ----------------------•---------------------- -------------------- <br /> Contractor's Name — = License # ------------------------ Phone ------------------------_.._-- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------------ Number of bedrooms _-____---__-Garbage Grinder ---__.------ `Lot Size _________________________-----___________ <br /> Water Supply: Public System and name ------•-----------------±----------------------------------------•-------------------- =--------------------Private E]Character of soil to a depth of 3 feet: Sand'❑ Silt F] Clay ❑ Peat❑ Sandy Loam •❑ 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 [ I 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 y'_---____----_---------- 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 ------------------Number;----- -------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth �ti 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 Requirements) ------------- ' --------------------------------------------- <br /> ----------' i <br /> ------------------------- -«._-------------------------------------------- <br /> ----------------------- <br /> ad ------------------------------------------------------------------------------------------- <br /> {Draw existing and required <br /> } dition 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 manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---- ----------- Owner , ► <br /> BY ------------------------ - --------------------------------------------------------------- ~ Title ------ --------- ------------------------------------------ <br /> (If other than owner) ` ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ------------------ ----------------------------------------------- -------------------------------- DATE <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE -- ---- ----------------------------- <br /> ADDITIONALCOMMENTS ------------- ------------------------------------------------------------------------------------------------------------ ------------------------------------ <br /> ------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> FinalInspection by- -----------------------------------------------------------------------------•---------------------------------------Date -------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'d8 Rev. 5M <br />