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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> _... ...... ....... Permit No--- --- <br /> (Complete in Triplicate) <br /> ------------------------- • --------- . . ----------- <br /> Date Issued... <br /> ................... <br /> ,This Perm it,Expires 1 Year_From Date Issued E <br /> Application is hereby made to.the San Joaquin Local H lth District for a permittoconstruct and install the work herein described. <br /> This application is made in complian7ce with County O dinance'.No. 549 and existing Rules and Regulations: <br /> i�`.._�i •..._ 11... - ----------- --CENSUS TRACT.._._......_._.-.....-.... <br /> JOB ADDRESS/LOC ION.. .-.tf.. ------ - -- ---- :f <br /> `' ...---- -- Phone ------ -- ---- -- <br /> Owner's Name...... .. .- . . ..... • - ....... 4 <br /> Address-------- _ --------•--------- r... is --t.....City----------- --- ......Zip--.:..... <br /> // l .....Phone <br /> -----......... <br /> Contractor's Name... ...... <br /> - . <br /> ' License { <br /> Installation will serve: Residence Apartment House [:]Z Commercial E] Trailer Court El <br /> otel ❑ Other........- ': ..................... <br /> Number of living units:.... Number of bedrooms.. .Garbag Grinder............Lot Size_...- �= <br /> Water Supply: Public System and name...... ...................... '� ' Private <br /> Character of soil to a depth of 3 feet; 'Sand 0 Silt 1 Clay Peat 0 Sandy Loam ❑ Clay loam ❑ <br /> Hardpan ❑ t Adobe ❑ Fill Material--.---- _.- If yes, type...................._....... I <br /> t i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r� <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) { <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ 1 ' Size4._.1 �. _ ©--:-•-•------------- --Liquid Depth. _- CS <br /> - <br /> Ca t dE.��... Type--A Material -- •---_No. Compartments.... _. <br /> e� , <br /> istance to nearest: Well_:.-.�--• - U. :.....:.............::.:Foundation------>l- ----...-...-.Prop. Line.......... .. ......... <br /> . - <br /> 3 <br /> LEACHING LINE [ 1 No:'�f;lines ._.�-----------------------Length of each line...- - -----------....-Total Length - - .___-.....--- -- ; <br /> i <br /> 'D`.Bo _-. -.Type Filter Material...../.- Depth Filter Material.-------_--------- •-------- ---- --------- <br /> -. undation...........:... . PropertyLine_... ` <br /> Diameter - ] <br /> SEEPAGE PIT ( ] Depth_.. 1 ------.Number....:_/ •--4----------------- Rack Filled Yes No❑ 1. <br /> Distan a to�.nea est: We ------------------------- � <br /> Water Table Depth-------------------------- .---.Rock Size. --- r <br /> Distance to nearest; Well-------•....... --_.Foundation------------------ ------Prop. ...... i <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------- -------'...Date---•----:---.._:.-.:`.-4..._- .>..'=__.__ .) 6 <br /> Septic Tank (Specify Requirements)---------------- - <br /> Disposal Field (Specify Requirements).---- ------ ................. ........... ...................-• =„= -•-- I <br /> ........................... --------------..-------- ...... _- ------ _ "..__.. ...................... -------- <br /> z <br /> r' <br /> --------- --------- --------------------- -------------- <br /> (Draw existing and required addition on reverse side) 3 <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 /> 111 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 pen tiot3 laws of California." <br /> Owner <br /> Signed.---- ---- ---------• ... -- _ -Z--ner <br /> - ...---.....------------ -...- ., <br /> BY - -- <br /> Title ----------------- <br /> (If oth r tan ) <br />[ FOR EPARTME T SE O Y <br /> APPLICATION ACCEPTED BY ------- - •... ..... .---/_ � <br /> - ........ <br /> t DIVISION OF LAND NUMBER. DATE - <br /> _---_----- ------ ---- - --- <br /> I ---- <br /> ADDITIONAL COMMENTS- ---------- -- ------ --------.---.- --- --------------- -- <br /> -------------------- ------r - Q .... b ::::: ::: : - ------- - <br /> ­--------------_------- <br /> ------------------------------------- <br /> _ __ ............. . .... --- <br /> _.. .. . <br /> - -------------- --..... .._ e..._-._.._.--- - _....... ..... <br /> Final Inspection b .. ..-- ----------------- ------------•------------- ----Dat <br /> EH 13 24 SAN JOAQLIIN LOCAL HEALTH DISTRICT Fas 21 7/76 3M <br />