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FOR OFFICE USE:, FOR OFFICE USE: <br /> _ APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------------------- --- Permit No.- ---- -- ----------- <br /> (Complete in Triplicate) <br /> Date lssued_1/~.�_-9. <br /> _ This Permit Expires 1 Year From Date Issued <br /> ..-_----.-----`--7-.__________ __________________ ___ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION__1W .7Q -�------�--: ......... <br /> ------- ----- - ----------------- ----.-CENSUS TRACT---------- ------' -- ------- <br /> a <br /> Owner's Name_ --------------- ----------------- ------------------------' ------------- -------Phone__g3$'_/'J <br /> Address - Ci ------------ --------------- ---- ---Zip <br /> Contractors Name__ License <br /> ' , ,#-����-�- -----Phone- W_4o 1?- ----- <br /> Installation will serve: Residence Z Apartment House ❑ Commercial ❑ -Trailer Court ❑ <br /> ,. Motel ❑ Other- --------------------------- =- <br /> Number of living units:-------/-------Number of bedrooms...o9--.-_Garbage Grinder---_--------Lot Size---. __.----= --------------_-_____.----- <br /> Water Supply: Public System and name------ ---------------------------------------------------- -------------------m-- -----------------------------------Private � <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ PeatL]- Sandy Loam >j Clay Loam ❑ h. <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 publicavailable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK '[ ] Size---- sewer s� 00 { <br /> ------------------------- Liquid Depth ^- <br /> Capacity---------------------TYPe--------- -----------MateriaIe&_VVLe&_--No. Compartments-. ------------"----------- <br /> f <br /> Distance to nearest: Well__ B� --`----- -- _-Foundation.- -_\___--______Prop, Line-- ---'t-____ <br /> -- <br /> LEACHING LINE [ ] No, of Lines-----o - ----------------Length of each line:-------- --a--------------Tota I Lengthy------ -_t-,_ - ------- <br /> 'D' <br /> -- --_D' Box---- ------Type Filter Material--,L-2-_/&, eDepth Filter Material_2----------------------------------------------------- --- � <br /> Distance to nearest: Well-_, d_n_----I---------Foundation-/6--J--f-------------Property Line------------------------------------ <br /> SEEPAGE <br /> ---------------- ------.---__SEEPAGE PIT [ ] Depth-la! ---Number----..-_a- - ------------------ Rock Filled YesV NoE] <br /> Water Table Depth--- -----------------------------------------------------Rock_ _ Size. ./-i- ------------------ ------------ <br /> Distance to nearest: Well.-.�©P__ ---___ __________________Foundation____�p----------------Prop. Line ----------- r- <br /> --:- <br /> i ] , <br /> REPAIR/ADDITION (Prey. Sanitation Permit#------------------------------------------------ -Date-------------.------ ------------- ---- <br /> - <br /> SepticTank (Specify Requirements)------------------ ------------------------------- ---------------------------------------=------------------ ---------------------- --------- <br /> Disposal Field (Specify Requirements)---------------------- ------ --- ---------------.---------------------------------------- -------------------------.---- <br /> --------------------------------------------------------- ---- <br /> (Draw existing and required addition on reverse side) '! <br /> I hereby certify that'l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules •and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the perforrnslnce 'of the work for which this permit is issued, I shall-not employ any person in such manner as <br /> to becomeub/''ect to <br /> Workman's Compensation laws of California." <br /> Signed � ..---------Owner <br /> t ` <br /> -- --- ----- --- =BY --------------Title-------- ------------------ <br /> (If other than owner) i <br /> F9F DEPARTMENT SE ONLY <br /> APPLICATION ACCEPTED BY----- - ----- ---------------------------- ---------- - -.-DATE ---2-- �" <br /> DIVISION OF LAND NUMBER-------------------------------------------------------------- ---------------------------------- ------- DATE-.---------------- ------ <br /> ADDITIONAL COMMENTS-------------------- ---------------------------------------=------=---------------- :--=---- <br />- ------------- --- --------- <br /> --------------------- ------- N �] <br /> =--- ------------------------------ ------ - --------------------- - a <br /> --- - - <br /> f <br />;._ Finai•Inspection by:_ '" --- - ------------- "= "- Date.-f 1.- - <br /> EH 13 24 SAN JOAQ LOCAL HEALTH DISTRICT F&s 21677 REV.7/76 3M i <br /> y rif'5 <br />