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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ...----�------------- - ---- - --------- --------- --- No..�/..-.:�¢-.7`a <br /> (Complete in Triplicate) Permit <br /> ------------------•-------- ------------ er <br /> ••••••-•••--•-••-----11----• ---- -------------- ------ This Permit Expires 1 Year From Date Issued Date Issued--S__- 99 7/9/ <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 Ordihance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ ?..L_.7..� ....... <br /> _ <br /> •. -- -� -------CENSUS TRACT.._..-.��... .................. <br /> Owner's Name.. Phone----------- <br /> �- - 7..................... <br /> Address. C- � -Zip---- <br /> Contractor's Name ...--�/1' -----� .......4License Phone- <br /> Installation will serve; Residence ❑ Apartment House D Commercial [❑ Trailer Court ❑ <br /> Motel ❑ Other...- <br /> - ................ <br /> Number of living units:......'1�---------Number of bedrooms............Garbage Grinder------......Lot Size.......... .. ... ................_..:.._.....__........ .. <br /> Water Supply: Public System and name................ ......................--- . ... .. ----------- ---------- - -----------------------------Private r-1Character of soil to a depth of 3 feet: Sand F) Silt [-IClay [IPeat E] Sandy Loom E] 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 [ J SEPTIC TANK [ ] Size............---------------------..._._-_--- --------...._Liquid Depth.--:----------------------- <br /> Capacity- ------------= -----.Type.......................Material------ ­ . --:No. Compartments--------------------------- <br /> Distance <br /> ----•=•----- ------Distance to.nearest: Well ................ -- ---......Foundation-•---_.... ......Prop. Li ----.... --- .----------- <br /> LEACHING LINE [ ] No. of Lines-------------- ---------- --Length of each line -___ ................... Total Length . ........_--••-----.................. <br /> 'D' Box--.--.......T e Filter Ma rial................. . pth Filte Material.................. .--------------------- .------------ - --•- <br /> Distance.to n crest: Well....._. .... -------------------Pro erty Line_...----------.--. <br /> SEEPAGE PIT [ ] Depth.-.............. . .....Diameter--------- ----Nu er--------.------ _ <br /> III p _ _____ _________ Rock Filled Yes ❑ No ❑ <br /> WaterT le Depth--.--------------- - - ---- ----------------------Rock ' e ---............... ------- ---------------- -- <br /> Distanc to nearest: Well-------•-•..................................Foundation_._. ._.. ...............Prop, Line.......___..---............ <br /> . <br /> REPAIR/ADDITION ]Prev. Sanitation Permit#---- ---------- - ------------ -----------Date.---------------------_........ <br /> .-------- <br /> ---. ) <br /> Septic Tank (Specify Requirements)......_----------- ------- _-- -_-- . ... -- ------ ----- _-- <br /> Disposal Field (Specify Requirements) <br /> --•-• - -------:------------ -.-- ------------------------------------------- <br /> -`-'---- Q-- - --- ------- -- ....---- <br /> - ------------- ----- ------ ------ -- = .................. - -...............-------- rhe' <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 worts 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 /> i <br /> ' EPARTMENT USE ONLY <br /> 4 APPLICATION ACCEPTED BY................ --.-DATE .----..------.SS•. - .7CI---.-----.- <br /> DIVISION OF LAND NUMBER....------- ------- <br /> DATE------------ --------- ---- - - <br /> ADDITIONAL COMMENTS----------- -- --- -- - --- <br /> .. . ... <br /> ----- ------------ ---- <br /> P '` ; <br /> v <br /> - <br /> I <br /> Final Inspection b { . Date" <br /> y: -------------- .. -9....... ..._ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F85 21677 REV. 7/76 3M <br />