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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- - ----- i ! Permit No. . �-. . <br /> (Complete in Triplicate) <br /> ------------------------- <br /> --------------------------------- ------------------------ This.Perm it Expires 1 Year From Date Issued <br /> Date Issued <br /> i . -. <br /> Application is hereby made to the�Son Joaquin Local Health District for a per to construct and install the work herein <br /> ty <br /> described. This application is made in compliance with Counrdinance o. 549 and existing Rules and Regulations: <br /> �j �. f <br /> JOB ADDRESS/LOC N .---©S_�--`----------------- - ---------u------ ------ M-----i-------------CENSUS TRACT .------------------------- <br /> Owner's Name yl;.;z <br /> ,. - Phone.- <br /> --------------------_ <br /> Address ------7 _ --�-- =' -y'`� '�---------. City -------------- <br /> Contractor's Name - ----- ---------s °---�-'--- a---------License # F Cl 6 Phone <br /> Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court ;❑ <br /> Motel ❑ Other __.__ - <br /> ------ - - - - --- ----- - - -- <br /> Number of living units:_- I__ Number of bedrooms - _______Garbage-Grinder --- ------- Lot Size _. — -- ' ----- <br /> Water Supply: Public System and name --------------------------------_--- -* _---Private [} <br /> I <br /> Character of soil to a depth-of-3-feet.—Sand-'E]—F Silt❑ CI ❑ Peat;❑ Sandy Loam -E] Clay Loam E]f <br /> t Hardpan F] ; Adobe Fill Material ------------ If yes,type ---------------- ----------- <br /> � I <br /> (Plot plan, showing size'of lot, Iocation of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage`pit_per mitt`ed''if:public sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT {i] SEPTIC TANK{[ ] Size-------------- - ---- Liquid Depth --------------.__________. <br /> Capacity-------------------- Type -------------------- Material---- ---------------- No. Compartments ----------------.:.._. <br /> I Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- _-••..- <br /> S. <br /> I LEACHING LINE [ ] No, of s <br /> Line - .--.--- t------ Length of each line--# l L <br /> ------------.------ Total ------•--------------------- <br /> i ti '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 /> t r Water Table Depth ---------------------------------------=--------Rock Size -------------------------------- <br /> i '^ Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----- -------------- <br /> REPAIR/AD'DITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ' ________-_­_ __ __'_____ ) <br /> Septic Tank (Specify Requirements) ------------------ --------------------•--------- ------------------•----------------------------- <br /> Disposal Field (Specify Requirements) -----------------------------• -------------------------------------------- ----------------------------------------- -------- <br /> --------- --------------- <br />[ --------------------------------------------------------------------- ---------- <br /> r {Draw existing and required ad ition 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 s. bject to Workman's Compensation laws of California." <br /> �- -: �- OwnerSigned --------- ------ ------------- <br /> BY ---------- ---- ------ -- --- ------------ -- -- --__. Title A <br /> 2-0 <br /> u--------------------------------- <br /> (If <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY - =--------------------------------------------------------- DATE ---------- <br /> BUILDINGPERMIT ISSUED --- -------`----------------------------------------------------------------------- --.-------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------- ---------------------------------------- -------------------------------------------------------------------------- ----- <br /> i <br /> - ------ -- ------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- ------ <br /> ------------------------------- -- - - - - ------ <br /> Final Inspection by: Date. --- <br /> ---------------------------------- ------------------- ---- / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />