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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> � (Complete in Triplicate) �- <br /> Permit No: ---------------- <br /> --------- ----------------------------- <br /> ---_____________________________________--_____ This Permit Expires 1 Year From Date Issued <br /> Date Issued _���c_-7__. <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 /> << JOB ADDRESS/LOCATION•/­­`,I-e,-:; --- ,.,C/mow-- --CENSUS TRACT -------------------------- <br /> Owner's Name 11, ___ - 7' r�/__ _ <br /> ,Mo_!r1 ? ,� �- _ - Phone ---------------------- <br /> Address c. <br /> -- - [.0 1� City <br /> Contractor's Name _ -_-_------License # 12� hone _, � � <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 ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam .0 Clay Loam EI <br /> Hardpan ❑ . Adobe ❑-- Fill Material--:-_------ If yes,type ---------------------------- <br /> (Plot <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: <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK''[ ] Size----- ------------------------------------------ Liquid Depth .------------------------- <br /> Capacity -------------------- Type -------------------- Material----------------- No. Compartments <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------------- <br /> 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 /> r <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 /> REPAIRfADDITION(Prev. Sanitation Permit# ____________________________ ____ _________ Date _______/_ _____-___.--__-___-_____) <br /> Septic Tank (Specify Requirements) ------------------------------------- ---------------------------------- --------- ----------------------------------------------�--- <br /> Disposal Field (Specify Requirements) --- -- ___ _ ----- _�_ __ __- a__-_ !Cji � <br /> - F <br /> X-��a------------- <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 manner <br /> as to becom ject to orkman's Com ation laws of California." <br /> Signed ------ `i�.� r __. .eC'�==---- Owner s <br /> f <br /> BY Title <br /> ------------------------------------------- <br /> ------ - - ---- <br /> - ------- --------------------- <br /> (If other than ner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- — <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------------------- --DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS <br /> ---------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- <br /> -- --------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------- <br /> Final Inspection by: ------------------ " __- ----------------------------------------- --.Date ---- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br /> Cb ! <br />