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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> Permit No.-,���f�/ <br /> ------------ <br /> ------------------------ --------- - ------ (Complete in Triplicate) <br /> _...___- Date Issued.��--lg-=� <br /> --------------------------------------- - - <br /> --- p <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 /> ` �� /� - TRACT _ <br /> JOB ADDRESS/LOCATIO CENSUS <br /> Owner's Name. --------- -�------- ----.------------------ <br /> Phone <br /> Address----- ----- /-----�--- rCity� ----------------------------- <br /> .-Zip <br /> ' one--- ------------------ ---------- <br /> Contractor's Name__.___-__ -- ���__..-�--------------License #_._�-'Z'��' -Ph <br /> �. - _ <br /> Installation will serve: Residence ❑1 Apartment House. Commercial Trailer Court ❑ <br /> ."Motel❑ !Other---- --�- - -----'--- --- ------ -=----- <br /> Number of living units ""--.--=------Number.bf bedrooms- --____,_"-Garbage Grinder_--'_`-____.:-.Lot Size---_: _.--"---- - - private <br /> 11 <br /> ,. <br /> 1 - -- --- ------------- -------------------------- <br /> Water <br /> --------- :------------- <br /> Water Supply: Public System and name ' ----------- ------------- ------"-� F <br /> depth of 3 feet; Sand ❑ Silt❑ Clay ❑ - Peat❑ Sandy Loam.Z?( Clay Loam ❑ <br /> _.. _ Fill Material = --If yes, type--------------------------------- <br /> Hardpan - r. M <br /> Character of soil to a de <br /> ❑...Adobe_[:) <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 taW or seepage'pit permitted "+f public sewer is available within 200 feet,] <br /> i t <br /> PACKAGE TREATMENT ] ]" SEPTIC TANK [ '1 <br /> Size-------------------------------------------- <br /> ----- --------Liquid Depth-----------------------=--- <br /> --Material---- ----- ---------------No. Compartments--------=-------------------------- <br /> i Capacity = TYpe ------------------- 4, <br /> • - � Prop. Line---------- --------- - <br /> Distanceito.nearest: Well--- ---•----------•----------=--------=----Foundation _-• ------ -:--- ---- <br /> r LEACHING LINE [ °] No:-of Lines------------------------------Length of each line._ -------,_- ----------------.Tofiai length ---: .-_,.,- ` <br /> _,-----Type Filter-Material-------------- -----Depth Filter Material__._______.__._----_"-- <br /> I Distance to nearest: Well_ --------------'------n___ Foundation. -___-- -.Property Line_____________________ <br /> 4 t ill Ye No El <br /> SEEPAGE PIT [ ) Depth--- = Diameter.'-----------------Number- <br /> R Filled ❑ . <br /> --------------------- <br /> € ->� .. <br /> « s <br /> [ Water •Table.Depth . = = _ Roc Size:_ <br /> I . ; ound n .:_.Prop. Line--------- ------------ <br /> Distance.to nearest: Well.__. -'--------- ------------------------F atio ----- ; <br /> J � - <br /> --.Date----- - �-- -�-� ----REPAIR/ADDITION <br /> -----------------------------------------Permit#_��' � -1_---- -------- _-------- i <br /> Septic Tank (Specify Requirements)-------- � ----=----------------------------- = ----- --- - <br /> Disposal Field (Specify Requirements).:._-"- <br /> F ------- ------------ <br /> . - --. -� -- ------- --------------f-- -:- . <br /> -------------------- <br /> - ----------------------------------- <br /> :_:. <br /> ----=------=----------------------- <br /> t t <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that ) have prepared this application and that,the work will be done- in accordance-with San Joaquin County <br /> j Ordinances, State Laws; and Rules and Regulations of.the_San Joaquin Local Health District, Home owner or licensed agents <br /> sign tu.re certifies the following: <br /> l "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 Co of California.''Signed 7nsatio"llaws <br /> i''2. ---------------------------------- <br /> Tit[- <br /> BY---------------= <br /> .' ' <br /> e. <br /> '(If-o-ther`than owner) ° <br /> x _ FOR,DEPARTMENT USE ONLY <br /> .: JJ <br /> DATE. F 'Z.� f- -----�`�-1S--- <br /> APPLICATION ACCEPTED. BY___ _ <br /> - ------------------------------ <br /> DATE--.-. _ <br /> DIVISION OF LAND NUMBER,._ =--.----=--- ---------- ---------------- <br /> ADDlT10NAL COMMENTS-----:---.-- <br /> - ---- --- -- ---- .------------------- ----- <br /> -- <br /> § --------- ------------ -------------------- - - ----- =�.---- . ---- ------ ------------- <br /> i ---------=--------- --- -- ---------------- ------------------ ------ --------._:. <br /> ----------------- <br /> ------ ------ - - - ------------------------- --------- ------------------------------ ---------- <br /> S <br /> -- --------- Date -1 <br /> '�-------------------------------------- <br /> �` --- <br /> b - -- ---- --- <br /> F1na1-Inspection• Y�-- --- --- ---- --- -- <br /> F&5 21677 REV. 7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />