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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No $�rp <br /> ----------------------- -------------- <br /> - ------------ � - (Complete in Triplicate) <br /> --------------------------- <br /> ------------ Date lssuedll-=/42-�,5r' <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---Z`-----�- 1----�-- ---- --'------- ��----- -- <br /> -------------- ---------------CENSUS TRACT------ -------------- --------- <br /> Owner's <br /> -----..Owner's Name------ . _. -- -- - --------------------- ----------------------Phone.--------------- -- ------- <br /> Address---------- t -----------Cit --`------- --------------- --Zip----------- ------------------ <br /> Contractor's Name d ----------License #---3ZZ-ZZ- -Phone---------------------------------- <br /> --� `�~--" <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.:-- 4. <br /> .... )-----Garbage Grinder------------Lot Size---------- Ar,`---'`�-a---------------•---------- <br /> Number of living units--------- -------Number of bedrooms <br /> Water Supply: Public System and name------ ---------------------- ---------------- - <br /> -------------------- ------------------------------------ ----------------- Private E]-- <br /> Character of soil to a depth of 3 feet:/ Sand E] Silt E] Clay ElPeat E] Sandy Loam E] Clay Loam ❑ <br /> Hardpan W 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 I ] SEPTICTANK [°1 Size_4_!``;;?._Ix.1-X-IS-11----------------------Liquid Depth <br /> Capacity 1Q` !!ZO------ -Type-- Material--.r--v"k-2_-------No. Compartments---- <br /> . <br /> Distance to nearest: Well---------------` ©--------------- -------Foundation------. _42_1---------Prop. Line------- ------------------ <br /> LEACHING LINE [41 No. of Lines-------------Y--------.Length of each line ._.__--4o_--_----------Total Length --- -i____.-- ----------------- <br /> 'D' Box-----t.--_Type Filter.Material.----.5-F-------.Depth Filter Material ._15-`--------.-------------------------------------------- <br /> / Distances to nearest: Well--._..__— --------.,_,_-Foundation-------- <br /> lfiJ.../----------Property Line-_..___S__._------------------------------------ ---------------------- <br /> SEEPAGE PIT I] Depth---- _,'� ;Diameter------._.. .Number_________________�_____ r Rock Filled Yes [51_�No ❑ <br /> Water Table Depth-------------------l<-9 fl----- ------------------------Rock Size-- ----------------- <br /> Distance to nearest. Well--------------- - -f -__r_-- -----------Foundation--------1-0--- --------Prop. Line-----_-----11,------------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------ ------Date-------------------------------------------- -) <br /> Septic Tank (Specify Requirements)---- -------------- ------------------------------------------------- <br /> Disposal Field (Specify Requirements) --------------- ----._ -------------------------- ------------------ <br /> ---------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------- <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 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 become subject to Workman's Compensation laws of California." <br /> Signed------------- ------------------- ---------------Owner <br /> By - -------------Title-- -- -- ----- - - - ------.. ------ ---------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__--'..____- DATE __ "�- -��1- <br /> ------- ---- <br /> ---- - --------------------- ----------------------- ` <br /> DIVISIONOF LAND NUMBER-- ----------------- --------------------- ------- ------------- ------------ ------- ----------- ..DATE.--- -------- -------- --------------- ------- <br /> ADDITIONAL COMMENTS - ---------- ------------------- �P <br /> d, <br /> -- ------------------ <br /> ,Q � -----yr�-�--- �P-------------- -- ------ - -4------- <br /> ----------------------------------------------------------------------------------------------------------------------------------- --------------------------- ----------- <br /> ---- --- -- -------------------------- <br /> ------------- -- ---------- <br /> Fi -- D <br /> y <br /> Final Inspection b � - ate--- ------ ------- ------------------------- <br /> Final <br /> --- -- --- <br /> Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV, 7/76 3M <br />