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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No_____________ _-----___ J <br /> Date Issued--- <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.I <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION �� . ------- � y.- --------------------------------------CENSUS TRACT------------------------------ <br /> Owner's Name /------------- ---- --------------- -- ------ ---Phone---- -------- ----------------------- <br /> - -- ----------- <br /> Address- ------ l._ a ------------ U _..-- City-- -zip-------- ---- ---------------- <br /> Contractor's Name-------- -_-- -License #___ ZPhone___________________________________1 <br /> Installation will serve: Residence Apartment House❑ ComJ�ercial ❑ Trailer Court ❑ <br /> Motel F-] Other__'27le-�-7_.19�'__.+_-_-_....... <br /> Number of living units:---- t___.___Number of bedrooms___.­7—___Garbage Grinder------- ---Lot Size_________ __________________ ______________._..___..__ + <br /> Water Supply: Public System and name---------------------------------------------- -- - -- --- ------------------------------------------I-----------------------------Private ❑ , <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 see age pit permitted�iff blic sewer,is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size_. Lf__�x_ -------X___�_--___________Liquid Depth.____�._ <br /> J <br /> Capacity- olgP._._____Type._,Vt4A0- _Material__._ -E�____No. Compartments____�,�_____'_____________ <br /> V / <br /> Distance to nearest: Well-----_____.��_.� _ ' <br /> __ _______________ ___Foundation__ �6_�_-_'.______Prop, Line.____"'___---------------_ <br /> _ <br /> if <br /> LEACHING LINE [til/No. of Lines.-_.--__J__________________Length of each line-------''__.__._____________.Total Length.__.___7� <br /> 'D' Box--- -----Type Filter Material _-_--7-_K___.Depth Filter Material____ ----------------------------------------------- <br /> r-'Distanceto nearest: Well_______ ------------Foundation___.___ --------------Property Lin e-------S-. --------------------- <br /> � <br /> SEEPAGE PIT <br /> [ , rDepth_p�� —Diameter_____ Y____-__.Number___-_______-�----------------- � Rock Filed Yes [�No ❑ <br /> Water Table Depth-----�-t}6 Rock Size---- <br /> to nearest: Weil_..______.____J_ p__ ---.--- ----- --Foundation---- --1-0- ___ Prop. Line--- 4 -------- <br /> REPAIR/ADDITION (Preva'Sanitation Permit#---------------------------------------------------Date--------------------- ------------------ -- -) <br /> (- <br /> Septic Tank (Specify Requirements)----------------------------------------------------------------------- -------------------- <br /> - ---- -------- ------------- -------------------- <br /> (Disposal Field (Specify Requirements)---------------------- -•-------_---- ------------------ - - ---------------------- --r------r ------------ -- -------- --- <br /> s : <br /> v'F ------------------------------------- ------ --------- <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: s <br /> "I certify that in the performance ofkthe 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----------------- - <br /> ------ ------------- = ---Owner <br /> BY - <br /> Title-----a.!( r/ke --- -------------- ------- ---------- ---- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE. ` ---- <br /> DIVISION OF LAND NUMBER I --------- ---------------------------------------------------DATE.----------------------------------------------- <br /> ADDITIONALCOMMENTS---------------------------I----------------------------------------------------------- -------I--------- ------- ---- ------------------------------------------------- <br /> -------------------------------------------------------------------------------------------- --- ----------------------------------------------------------- <br /> - ---------------------------------------- --------- ---- <br /> Final Inspection b l -----------------------------__Date------_ _ ____ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT G&S 21677 REV. 7/76 3M <br />