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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------•----- <br /> (Complete in Triplicate) Permit No._2.g:.g -.- <br /> ............•------------•........ ------ ----- This Permit Expires 1 Year From date Issued 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 0 di No. 549 and existing Rules and Regulations: <br /> m.. . <br /> JOB ADDRESS/LOCATION.__... ® U-- - <br /> 6 . . I <br /> -- ---- 1-- ------------------ •------------ . ----..CENSUS TRACT_.......................... <br /> ..... . <br /> Owner's Name.... . --- --------- ................................ ...... ......Phone --------------------------- <br /> Address------... b 0. . . .. ----- .....City---.. ------------------------------ Zip--- •---•---------------- <br /> Contractor's Name.-... �. ..........................LicensePhon..,9(7149.040/--------> <br /> Installation will serve: Residence ❑ Apartment.House ❑ Commercial ❑ Trailer 1,111W <br /> 1. <br /> Motel (� Other- -------------------------------- <br /> ---- <br /> -- -- -- ------------- -- ------- <br /> Number of living units:.. ......Number of bedrooms......:Garbage Grinder------------Lot Size-----f...... _-...._._ <br /> CCT- .------ . <br /> Water Supply: Public System and name------- ----------- -------------- - •-- • J-- - -----....Private 'I <br /> Character of soil to a depth of 3 feet: Sand [D Silt El Clay ❑ Peat ❑ Sandy Loam E] 'Clay'Loam <br /> Hardpan ❑ :Adobe ❑ Fill Material . .... -...lf 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...�4.................. <br /> Capacity.f ... !ype -�----........Material • ------No. Compartments .- .,�Z ------ ----------•-� <br /> Distance to nearest: WeiL.. � ...... .. ... ... .........Fouridation...--ir.............Prop. Line.....-..-- --- --•-_-----.. <br /> LEACHING LINE . [ ) No. of Lines _... .---------------------Len.-Length of each line._...- . <br /> g Total Length _ J r------------------------ <br /> 'D' Box . --...Type Filter Material....................Depth Filter Material_ .-------------------.----------------.--.................... <br /> Distance,to nearest: Well------- ......... Foundat' n----------------------------Property Line.....--...--.----.------------ ---- <br /> SEEPAGE PIT [ ] Depth--- .�._ _.Diameter.... ...Num ber. .....----------------- Rock Filled Yes . No ❑ <br /> Water Table Depth-- - -------Rock /,�c <br /> ---------- ------------------ <br /> Distance to nearest: Well....................... ...................Foundation...---------.............Prop. Line........---------...._...-. <br /> REPAIR/ADDITION {Prey. Sanitation Permit#............... ................................ ...............Date-------------_. _._. ...._.... <br /> ..-.-} <br /> Septic Tank (Specify Requirementsl_----- --------------- :-------.--.----------.---------. <br /> Disposal Field (Specify Requirements)----- --- ------------- -------- ------. ....--- ------------------------------------- --------- <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 /> { other than owner) <br /> FOR DEPARTMEASIT USE <br /> ONLY <br /> APPLICATION ACCEPTED BY_.. -.. - -DATE ....A0.-3'.2a--------------- <br /> DIVISION OF LAND NUMBER. :. ----------- <br /> ------ ---.DATE...._. ..... .. . ........---... <br /> . <br /> ADDITIONAL COMMENTS.................... .................................. <br /> --------- <br /> - -- <br /> ------------------ --------- ------------------------------ - ------------------------------------- -------- -- - <br /> rTS K 1D.�5:�'8-------------------- - ------------ ----------- <br /> ----------------7-:------------------------- <br /> ------------------------------------------------------ ---------- -------------- - - <br /> Final Inspection by:. ... . ------------------•----------- -----......- -Date.....)0'_ " ... <br /> EH 13 24 SAN JOAQUIN LOCAL HE DISTRICT FSS 21677 REV. 7176 3M <br />