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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.. <br /> ---------- ------- --------1------------------------ (Complete in Triplicate) <br /> -------------------------------------- Date Issued <br /> This Permit Expires I Year From Date Issued <br /> ---------------------------------------------------- <br /> Son Joaquin Local Health District for a permit to construct and install the work herein <br /> Application is hereby made to the Regulations: <br /> described. This application. is made in compliance with County Ordinance No. 519 and existing Rules and P <br /> 0 e ---------.-CENSUS TRACT -------------------------- <br /> 3----- ------ ---------------- <br /> JOB ADDRESS/LOCATION <br /> Phone -------------- --------------------- <br /> -------------------- <br /> Owner's Name ----- ----- - --- <br /> Address --------- ------- 71- ----------------- city ------------------------------------------------ <br /> --------- <br /> 4 -d_� -_f ------------------------- <br /> .-----.License # ?6hone <br /> Contractor's Name ---- ---Z�� <br /> Installation will serve. ResidenceApartment House,F­1 Commercial :ElTrailer Court 'El <br /> \ motel E]Other ------------------ ------------------------- Lot Size ---- --------- ----------- <br /> Number of living units ------ Number of bedrooms __:3------ <br /> Garbage Grinder ------------ ---------- <br /> Wat�r Supply: Public System and name ------------------------------------------------------------------------------------------------ ------------Private <br /> Character of soil to a depth of 3 feet: SandE] Silt 0 Clay E] Peat El Sandy Loom -El"'-Clay.Loam 0 <br /> Hardpan ❑ Adobe [] Fill Material ------------ If yes,type ---------------------------- <br /> - <br /> (Plot)plan, showing size of lot,, location of system in relation to wells, buildings, etc. must be placed on reverse side..) <br /> permitted if public sewer is available within 200 feet,) <br /> NEV�INSTALLATION. (No septic or seepage pit perm <br /> Liquid Depth --------------------------- <br /> PACKAGE TREATMENT [.1 SEPTIC TANK ] Size------------------------------------------ <br /> ----------------------- <br /> Capacity --------------------- Type -------------------- Material----- ---------------- No. Compartments <br /> Foundation ---------------------- Prop. Line ----------- -------- <br /> D.istance to nearest-,Well ----------------------- ------------ <br /> N <br /> ------ Total Length ----------_---------------- <br /> LEACHING LINE No. of Lines ------------ -- -------- Length of each line. <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------- <br /> Distance to - <br /> nearest: Well ------------------------ <br /> - Foundation ------------------------ Property Line ------------------- <br /> SEEPAGE PIT Depth --- Diameter I---------------- Number ---------------- ----------- <br /> Rock Filled Y6s No <br /> WaterTable Depth ------------- --------------------------------Rock Size -------------------------------- <br /> elf "___:'-:"" -------------- <br /> ------.Foundation -------------------- Prop. Line ------------------- <br /> Distance to nearest: W -------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit ------------------------ ------------- Date ----------------------------------) <br /> 101--------------------------- <br /> Septic Tank (Specify Requirements) ------------------------------------- ------------ ----------------- --------- ---------- <br /> Disposal Field. (Specify Requirements)' <br /> ____ - I____1----—---------------------- <br /> ------------------------------------------------------------------------------------------------------------- <br /> ------ -- ----------------j 0 <br /> ----------------- <br /> -------- ---- -- - - - - ------------- - -- <br /> ------ ------------- -------- ------------ - ------------ -Draw existing and required addition o n reverse si d e) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> se&agents signature certifies the following: 6 vied, I shall not employ any person in such manner <br /> 1.1 certify that in the performance of the work-for which this permit i issued, <br /> I California." <br /> as to becomes to Workman's �Co nsation laws of <br /> _tWM-r_ <br /> __ -0 _ <br /> e -- ---- ---------- ---- <br /> Titl _,c <br /> _� :,ar—- ---------------------------------- <br /> --- A2o <br /> By -------------- - -- ---- ----------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> I - - <br /> APPLICATION PLICATION ACCEPTED BY ------------------ DATE r_-�_-7------ ------------- <br /> . .................. DATE - --------------------------- ------------ <br /> BOLDING PERMIT ISSUED ------------------- ---------------------- ------------------ -- ---------------- ----------- ----------- <br /> ADDITIONALCOMMENTS ------------------- ------------------------------------------------ ------ --------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- -- - -------- <br /> --------------------------------------------------------------------------------- --------------------------------------------------------------------------- -------- <br /> ----------------------------- -------- - - ------ ---------------------------------------------------------------------------- -- -------- <br /> Date <br /> Final Inspection by. ------------------------------------ ----I- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. 9 1-'68 Rev. 5M <br />