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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> {Complete in Triplicate) Permit No. ..7. .`. ... <br /> -------------- ----------------..... <br /> ................ ............. ....... this Permit Expires t Year From Date Issued Date Issued ..I' _.. <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/LOC ION .._... CENSUS TRACT .......................... <br /> Owner's Name . .......... ...... Phone ......... .......................... <br /> Address ...._ <br /> _. .. .. _ _.�--��---�---- - ------• ------ ---- city .... .. .......... ._.._. .........---...........__........_... <br /> Contractor's Nome �-- _------- -•- <br /> License .34P.tA—. Phone <br /> Installation will serve: Residence❑Apartment HouseC] Commercial ❑Trailer Court C] <br /> Motel ❑Other .._-'A -- ---- -------------- <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❑ 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 of seepage pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f j Size................................................ Liquid Depth .......................... <br /> Capacity --------- ---------- Type ..---------------_ Material...................... No. Compartments ......................0 <br /> Distance to nearest: Well ....................................Foundation ............._. ...... Prop. Line .....................' <br /> LEACHING LINE [ ] No. of Lines .................. Length of each line............................ Total Length ............................V <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 <br /> Water Table Depth ------------------------------ ----------_----Rock Size ..................___...... <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitdtion Permit# ---.--------..--_ -------------------------- Date ................................. ) <br /> Septic Tank (Specify Requirements) -------------- - ..................... ....................... <br /> Disposal Field (Specify Requirements) °' .. <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 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 /> APPLICATION ACCEPTED BY .... Z _ --- ----- --------- ------------------ ---------------•---------------. DATE .� . s� <br /> BUILDING PERMIT ISSUED .---------_--------_--- --------------- ----------------•--.-.,-....DATE -..._--------------------------- ......... <br /> .ADDITIONAL COMMENTS ----- -•... .............. <br /> ------------------------------------------------------ ----------------.......... ........_........ <br /> ----------------- ----• <br /> Final Inspection by: '--- `- ---- -------------------------------- -------- Date ... .. .. _. <br /> EH �3 24 1'-58 ;tet'• � SAN JOAOUIN LOCAL HEALTH DISTRICT 8�7� 3M <br />