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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - -- -- ------------ Permit No. -- - --` <br /> (Complete in Triplicate) <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 permit to construct and install the work herein <br /> described. This application is tmade in compliance with County Ordinance No. 549 and existing Rules and Regulations: � <br /> JOB ADDRESS/LOCATION --------------------------------------------CENSUS TRACT --------------•------- <br /> Owner's Name - ------- - ------ Phone ---------------------------------- <br /> AddressS - ' `--- ------ ---. City ------ ----------------------------- •---•-------------•----- <br /> Contractor's Name ------- -- ---- - _ License #l,S'�_3 _y- Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -----------------------------------•-------- <br /> Number of living units:_________ Number of bedrooms 3_______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 E] Peat ElSandy Loam Clay Loam E] <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 /> I <br /> NEW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is available within 200 feet,) \ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size,, - -4- _X---_s- Liquid Depth _51--------------- <br /> Capacity - -=s -_ Material��-a� Type e -- - _____ _ _ ______-No. Compartments ---`�------------- <br /> r <br /> Distance to nearest: Well. ------------- _0__i______________Foundation ------I0--__------- Prop. Line __«X--------------- <br /> Q <br /> LEACHING LINE [,/"No. of Lines -------3 -- Length of each line-----7p------------------ Total Length ----------- <br /> V <br /> ._'D' Box - -- Type Filter Material ----5. '-____Depth Filter Material ----- ------------------------------ <br /> Distance to nearest: Well ------S47___________ Foundation -----la_- ---------- Property Line __-V-----------_...... <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. Sanitation Permit# -------,._..,------------------------------- Date -_-_--_-_______________________-__l <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 /> rT ----------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - -- --- --------- ----- --- --------------- �------- - DATE Vf ---------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------- ----------------------------------------------DATE ----------------------------------------- <br /> ADDITIONAL COMMENTS ------- ----------------------------------------------- ------------------------ -------------------------------------------------=---------------•----------- <br /> ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- <br /> --------------- <br /> ------ ---- r <br /> ---------------- ------ <br /> Final Inspection bY: - -- ---•--- ----------------------------------------------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M R` � <br />