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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------- <br /> (Complete in Triplicate) Permit.No.-7..-.-30---.- i <br /> Date <br /> .•----------------------------------- ............. This Permit Expires 1 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 described. <br /> This application is made in compliance with County Ordinance No..549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ...--- .. .._-.. _ _..CENSUS TRACT--_..._--- ..-.-- . <br /> ./-l-U-f/`c!' :----.L.l--¢`'�,------- ------------ --------- - ..... -- ----.-......----...--..:. --- Phone -e�..`-/6.-!'i'.�..-..-... <br /> Owner's Name.-... ,. <br /> Address {r - City Zi <br /> P <br /> - - <br /> Contractor's <br /> Name_...... c'- -- ---License #------ ----------------Phone--.---- ----------- --- <br /> Installation will serve: Residence EF Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----- - ---- ----- ------..-..---------- <br /> Number of living units:..... _-------Number of bedrooms...Y__.. .Garbage Grinder------------Lot Size. 3.. -'. - .- <br /> Water Supply: Public System and name -- ----- •......... - ----------------------------- - ------------------------ <br /> Character <br /> .------- -------------Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ 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 [ ] Size............. ----•----------------------..............----Liquid Depth.-----------------------s- <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 /> 'D' Box..... --....Type Filter Material........_.- -.---- Depth Filter Material-------------------------------- ---------------------....... <br /> Distance to nearest: Well------------------------------ - Foundation----------------------------Property{'Line............................------.� <br /> SEEPAGE PIT -- <br /> [ ] 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-----------....--------....................... <br /> ) <br /> Septic Tank (Specify Requirementsl-------- ---------- •---- ................. --- ---- - ----------------------- ...................... . -------- <br /> Disposal Field (Specify Requirements)-- --- ---• ---- - - - ---------.4.--. <br /> --------------------------------------------- - ---------••-•----------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to becom --� Wo km---n--'s-- Compensation laws of California." <br /> Signed-- -- --- -�....... ------ --Own <br /> er <br /> By.......------- - --- --------------- --------------------------- ------ Title-------- ------------------ .......... ................... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- ------- --------- -...-..- .......... --------- ----------DATE ---- ----- <br /> DIVISION OF LAND NUMBER-------- ........DATE._.... -- - --------- - -------- <br /> ADDITIONAL <br /> -- -- -ADDITIONAL COMMENTS------.............. <br /> ------------=----------- ---------- . --------.-....--......- ------------------------ ..........._..-....................... ---- -- - -- .............. <br /> ---------------------------- - - - ..---- -------------------------- ----...-- <br /> Final Inspection b - ­------------------ ---....-. 2 x—B T <br /> -- ---- ------------------- Date. - ... ..._. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />