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FQR OFFIq VSE: ` <br /> �yy/� r� - <br /> APPLICATION FOR SANITATION PERMIT <br /> .. .,.1p' ..._ __ <br /> {Complete in Triplicate} Permit No. <br /> ------------------------------ --------------- <br /> ---------------_-------------------------_--------------- This Date Issued Permit Expires ] Year From 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 Mules and Regulations: <br /> JOB ADDRESS/LO TION 3 3 ---CENSUS TRACT '��------------------ <br /> Owner's Name ----------------------- <br /> ---- Phone ------------------------------------ <br /> CityAddress -F ` ------------------------------------------ <br /> __ _License # -Contractor's Name_-__ ___. <br /> Phoney _ / /7--------- <br /> Installation will serve: ResidenceoApartment'House-❑`Commercial ;[]Trailer Court ;E] 1 <br /> 1_ a <br /> ` Motel ❑Other -------------------------------------------- <br /> Number of living units-----L__---- Number of bedrooms ______Garbage Grinder _ ___ Lot Size -_ _ ---------------------------- <br /> Water <br /> _�._S_�--___._. <br /> a <br /> Water Supply: Public System and name -------------------- <br /> •------ --.-_- --------------- - -------- ---------- -- - Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam;❑ <br /> i, <br /> t g 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 publicsewer is available within 200 feet,! <br /> PACKAGE TREATMENT { ] SEPTIC TANK[ ] Size_________------------------------------------------------- Liquid Depth --------------------- . ! <br /> Capacity ------------------- Type -------------------- Material- --- No. Compartments ---------............ <br /> Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line -----..___------------ <br /> LEACHING LINE [ ] No. of Lines ------------ Length of each line______ ____________________ Total Length ---------------------------- <br /> } <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------.------------------------„1 <br /> Distance to nearest: ''Well ------------------ <br /> ------ Foundation ----___-.-- --------- _ : <br /> __--.--_ Property Line . _____-. --__ l <br /> SEEPAGE PIT [ ] Depth ____________________ _Diameter„ ---------------- Number ---------------- ----------- Rock Filled Yes ❑ No i❑ t <br /> Water Table Depth ------ -- --------------------------------------Rock Size ---------------------------- <br /> t Distance to nearest: Well ______________________ p. <br /> ------------------Foundation -------------------- Pro Line ---------- .......... <br /> f -- - ' --} ._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --_- ________ ________-___________------ Date ------------------------ ------ <br /> Septic Tank (Specify Requirements) ---------------------------------•---- -- -- -- - - <br /> ---------------------- -------- - <br /> -- --------- <br /> Disposg Field (Specify Requirements) <br /> ------ ---- --------------------------—------------------------ <br /> s_ <br /> ---------------------------------------- <br /> I (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 /> 4) <br /> sed agents signature certifies the following: '� <br /> "I certify that in the perfor nee of the work For-which this permit is issued, I shall not employ any person in such manner, <br /> as to b me ubie;t t W r man's o nsation laws of California." I <br /> Signed ------------------------------ Owner a <br /> By ------------ 1 -------------- Title ------------------------------- <br /> 1 (!f h r tha owne <br /> _ F EPARTMENT USE ONLY�' <br /> APPLICATION ACCEPTED BY ------- - --- ------- -------- -------------------------------- ----- ----------- DATE - ---------- I <br /> BUILDING IPERMIT ISSUED ----------- - -- ---Vt7------------------------------------------------------------- ----------------------------------------- <br /> ADDITIONAL COMMENTS r; - --------------- --------------------------- <br /> ------------------ .... . _.... �. <br /> r <br /> ----------------------------------------------- --------------------------------------------------------------------------------------------- <br /> FinalInspection by: ------------- - --------- -------------------------------------------------------------------Date ,d <br /> SAN AQUIN LOCAL HEALTH, DISTRICT t �� <br /> E. H.49 1-'b8 Rev. y <br />