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FOR OFFICE'USE: APPLICATION SANITATION PERMIT <br /> Permit:No: <br /> - (Complete in Triplicate) 0 <br /> --------------------------------- <br /> Da#e Issued <br /> _------____- This Permit Expires 1 Year From bate 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - '' ----------------- --- , ' ------ --CENSUS TRACT ---------------- ---.... <br /> )).. '' Phone -- <br /> Owners Name -----f!'�- -- - - �-�"�-= '"" --------------------------------------------------------- ��-- -�--•- ---------- <br /> Address -------A---'�---Z- "° ---------------------------------------- City -n-------- <br /> - <br /> Contractor's Name ' - .��t_:.- ----------------------------------------------I-----------License # -------- --------------- Phone =--------- _------------ <br /> Installation will serve: Residence fe Apartment House❑ Commercial ❑Trailer Court <br /> v <br /> Motel ❑ Other -------------------------------------- <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size --------------------------- ---------------- <br /> Water Supply: Public System and name ---------------------- ------------------------------------------------- ---------------------------------- ---Private ❑ 4 <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,#yp J-------------- <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.[ ] Size---------------------------------------- - Liquid Depth __.---------------_------ <br /> Capacity --------- ---------- Type -------------------- Material--------------=------- No. Compartments ------ --------------- <br /> Distance <br /> ------------------------------------ <br /> nearest: WellFoundation ------------------I--- Prop.line -------- --- -------- <br /> LEACHING LINE ] Noof Lines ------ <br /> Length of each line <br /> ----------------------- Tota gt _-------- -------•----• - <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------•-----.- ----------------- -- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property line ----.--___________-:_-- <br /> I SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled` Yes ❑ No i❑ <br /> Water Table Depth ---------------------------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 /> - - — -- _ _ -t--- ` - ---- ----------- <br /> ------------ <br /> (Draw <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 /> kBy ------6._. G_ � � � / `- �-------------- Title ---------------- -----------------------------------=----------------- <br /> a (If other than owner) 0 <br /> FOR DEPARTMENT USE ONLY <br /> i - <br /> APPLICATION ACCEPTED BY ---- ------------------------------------------------------------ DATE _ �. -'_? <br /> BUILDINGPERMIT ISSUED --------------------------- --------------------------------- - -------DATE -----------"------------------------------- <br /> LADDITIONAL COMMENTS ------------------- ------------------------------- --------------------------- ------ - ------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------- <br /> ----------------------------------------------- } <br /> -- -F--=------------------------------------------------------------------------ -------------- <br /> Inspection b f -: -f��--------------------•--------------------------------------------------------------.Date s �j fJ <br /> to <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H'9 1-'68 Rev. 5M, <br />