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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> f (Complete in Triplicate) Permit <br /> ---------------------•-�-�..----- ------ ------......--. f-7-rj� : <br /> -- .. This Permit Expires 1 Year From Dote Date Issued-�}."_ <br /> Issued ! <br /> M <br /> I Application is.hereby made to.the San Joaquin Local Health District for a.permit,o construct and install the work herein described. <br /> f This application is,made in compliance with County Ordinance`�Na':'54'9-and existing Rules and R' ulati ns: <br /> i �N - ~ CEN <br /> JOB ADDRESS%LOCATION.---•- - --= <br /> ILL...- RACT...--------------------- <br /> Owner's Name.... . ; <br /> ....................... •---- .hone... <br /> 1 <br /> Address....-----i- Q .- { <br /> -- .... ........ ....City -------- - ---_----•--------------`. ---. zip- <br /> t�Contractor's Name.--.... .-. _ --------•---------•-- --. <br /> � <br /> f< fs ---...License # ...� f�#..Phone. ftInstallation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> ' Motele <br /> ❑ Other..., <br /> Number of living units:......- --------Number of bedrooms .---_ _�Garbage.Grinder.............Lot Size-------�/��_�^�_..�-��---,----------- <br /> Water Supply:'Public System and name.... _ Private <br /> ...--.... El <br /> ---•-•-----------•---• •-------- ------------------------ <br /> Character of soil - <br /> oto a depth of 3 feet: Sand E] Silt El Clay ❑ Peat El Sandy Loam ❑ Clay Loam ❑ <br /> v <br /> - Hardpan ❑ �Adobe ❑ Fill Material__ __.. ....If yes, type...........!--------- --- - ----� <br /> (Plot plan, showing size of lot, location of 'system in relation to wells,.bui.ldirigs, etc °must be placed-on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer'is available with n1200 feet,) <br /> IPACKAGE TREATMENT <br /> [ } SEPTIC TANK [ } Size.- ---------------------------•---`---------- ..-.-:Liquid Qepth.--.----=---------.- <br /> Capacity.. ..... 11 <br /> 50 <br /> TYPe•------------ -- ......Material----------------_-------!No. Compartments--•----- <br /> g t'� <br /> Distance to nearest: WeII.- ------ ----------- -------Foundation_!._.. ----...- ..'..Prop. Line-------------- - ...... <br /> LEACHING LINE [ l NNG%of lanes....... Z+-`-k:�...--- -_Length of'each line.................. Tota! Length .................._----....... <br /> ------- <br /> 'D' Box_ .....-- Type Filter Material. ..........Depth Filter Material------------------ <br /> ------------------------------------ <br /> ------ -- <br /> ,;Distance to nearest: Weil---------------- ..........Foundation----------------------------Property Line.------_------=---..-.-..-._-.. -. <br /> SEEPAGE PIT�tf [ } Depth ---._J---Diameter------------ ...Number......... ------------------ lRock Filled Yes ❑ No <br /> Water,Table Depth - Rock Size.._..- ------------------------- <br /> Dis ante to nearest: .Well--:----:-•----------------------------------Foundation ..--------.Prop. Line....------................ <br /> REPAIR/ADDITION'(Prev. Sanitation Permit#-.... ..... : -°-�. -_ .............--Qate------------------ ................. -----•--..) <br /> Septic Tank (Specify Requirements)--- ---------- j #, <br /> Disposal Field {Specify Requireme ts) -- ` ' ••:�4 <br /> � . <br /> ----------------- -- fi .-------...-------.---.---.. ----------- <br /> t <br /> ------------ -- -------------------------------------------------- ------ -------------------------------------------- <br /> IDraw 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: i <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 Com' pensation' laws of California." <br /> Signed--.. -Owner <br /> BY ..- <br /> 7iIle- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY......... + - --••--------------__------- - ----------------------------.-..:...DATE .-'y -x)-A)q----.-.--.-_------ <br /> DIVISION OF LAND NUMBER......... ............... F <br /> - - ---------------------------_----...--------------...----------------...------ DATE.---...------------------...- - --...-------.. <br /> ADDITIONAL COMMENTS.....................� I <br /> --------------------------------- -------------- .............. ------------•---------- -------------- --------------------------------------- --------------------------- ................... .......... <br /> ....................................... -------- ------= -.-------------------- -----. <br /> ---------------------- - ` <br /> K1 <br /> Final Inspection by;. - ��� ----------------------------------------- ----------- -- --- --------------------------------Date_1A� -0--1 --- - --- - ----- - --- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT - F&S 21677 REV. 7/76 3M <br />