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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ...... ....................... 7S` 7 L <br /> (Complete In Triplicate) Permit No. ........... ......... <br /> ................. This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliances with County `Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION,,. ----.7---- _-- -- ......__...................CENSUS TRACT <br /> Owner's Name .. � .�... .. !1�....... :...._..... Phone .................................... <br /> Address ................1� �J� City ... .....---..............---••--- .......... <br /> r� <br /> Contractor's Name . .. __.License # llor.3�2 Phone ..... <br /> Installation will serve: Residence (�partment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other ..............•----•-----------_---------- <br /> Number of living units:.--../----- Number of bedrooms .2.—....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 C] Sandy Loam Clay Loam 0 <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 [ ] SEPTIC TANK,1 ] Size.........................._......... ---------- Liquid Depth .......................... <br /> Capacity .................... Type .................... Material---................... No. Compartments ................__ U1 <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 -.-._..--_ ............... n� <br /> Distance to nearest: Well ............ Foundation ...._...._ ............. Property Line <br /> SEEPAGE PIT O Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No C] <br /> Water Table Depth ------••-•••••. ...--•..............Rock Size ................................ <br /> Distance to nearest: Well -_-_--_-•...............................Foundation ... ................ Prop. Line ....I............ <br /> . <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..........................._________________ Date ) <br /> SepticTank (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 /> "1 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 ........................................ .... ... . ....... Zner <br /> By ..... ......................_.....----•-_._ .. :�_....... ... .... .... c 4he...._..._...__._.... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> gry <br /> APPLICATION ACCEPTED BY ............... .............. __..... ..... , DATE ... .7.5..7........... <br /> BUILDINGPERMIT ISSUED .----.....-•-•------••---•.............. ... •-•--•--•-----•..•---.---....•-----._....-----.._............DATE ................... ....................... <br /> ADDITIONALCOMMENTS .......................-........................................-......._... .............................................--•.•-•-----------------.._...------ <br /> .........................•------........------..._...-•-.......--•-..------...........................•-••-•-•--......•--••••--•--------•-------------------------..............---------........._....._.. <br /> • . ..__..._... <br /> -- <br /> FinalInspection by: ...............•--......... ...-------•--•--•--•-. .-------•--....------••------.-------------------------------Date ...._.l .+ ..T-r..----•--•-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT \ <br /> E. H.23 241-'68 Rev. 5M 7/723 M <br />