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FOR OFFICE USE: <br /> F aAPPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br />' ----------I-------------- ------------------------------- <br /> __ ______________________________ t This Permit Expires 1 Year From Date Issued Date Issued <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/LOCATi `00 3 JAZ <br /> --------- - <br /> ------------- --------------------- -----CENSUS TRACT -------------- ----------- <br /> Owner's Name -------- ---------------------------------------------------3Phone --- 44__ <br /> -- ----- --------- <br /> Address ----------------- 6 ---------------------- City ---------------------------------------------------------------------- <br /> --- - - ---------- ---- -- - <br /> ' ,,``6 6-l'60 7 <br /> i Contractor's Name -- - - ----------------------------License #lC 1�----- Phone _T"_------- /•-- <br /> r <br /> t Installation will serve: esidence Apartment House 0 Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other ------------------------------------- / <br />` of living units:__________ Number of bedrooms --__:Garbage .m r _.__------- <br /> ---------------------------- <br /> ______ Lot Size -------------------------------------------- <br /> Number ° -----------•--.----- -• -- .Private ❑ <br /> Water Supply: Public System and name _______________________ ❑ �.____ .__ <br /> - -------- ---- - { ; <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt ""ClayPeat 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 or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK T"1. ,k z Size------------------ ----------------------------- Liquid Depth -------------------------- 0 <br /> Capacity -------------a- - Type --------e! ------ Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well --------`---j--------------------'Foundation ---------------------- Prop. Line -------------:------- <br /> LEACHING LINE [ ] No. of Lines ______________ ____ Length of each line---------------------.------ Total Length ,______-__._______--______- <br /> 'D' Box _ --------- Type,Fiiter..Material-=----=,_-_:-----Depth.Filter Material ------------------------------------- ...... <br /> Distance to nearest: Well _______________________ Foundation -------- ---------- - -- Property Line ---.--_._-.__ .......... <br /> SEEPAGE PIT [ ] Depth ___ _______ _____ Diameter-'•____--I_________ Number ------------ ___._________ Rock Filled Yes ❑ No Q <br /> Water Table Depth ------------- <br /> -`. W Rock Size t - <br /> Distance to nearest. Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> I ,,. t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> 1 <br /> Septic Tank (Specify Requirements) -----------'-------•----------- <br /> 0 <br /> Disposal Field (Specify Requirements) = a -- --------------------------------------- <br /> 6 1M----------------- -•---------- <br /> i <br /> ----------------------------------------------------- --------------------------------. - <br /> ---------------------------------------------- ---------------------------------------------- <br /> (Draw existing and req.uired addition on reverse side) <br /> 1 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.--; r• _ __ _� <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 /> s ]� <br /> • Title ----=- *`,--=------------------------------------------------ <br /> By -------------------------- ---- ----------------- <br /> (If other than ow <br /> I�D VMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ -----------------------------. DATE ----- --f - ------------- <br /> BUILDING PERMIT ISSUED ------- i - ---- ------------------------- -----------------------------DATE <br /> ADDITIONALCOMMENTS ------ ----- - ----- --- --- ---- -----------------------------------------------------------------------------------= <br /> ------------------------------------------- ------ - - ----------------------------------- ------7--------------------------------------------------------------------------•---- <br /> --------------------------------------------- --------------- <br /> Final Inspection by: - ------ --- ---- - --- - - -- --- --• --- . --------------------------------------------------,Date --- --”- 3 � <br /> �--------•------- <br /> A QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />