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i FOR OFFICE USE: <br />' ........ . <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> -- .... .. <br /> (Complete in Triplicate) Permit <br /> ------ <br /> This Permit Expires 1 Year From-Date Issued Date <br /> I <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 /> tR <br /> JOB ADDRESS/LOCATION-------------J <br /> Owner's Name.... .. <br /> _.. a- <br /> �------ ---------------- ------.CENSUS TRACT-,-,................ <br /> .......... . �'' -' <br /> t..... . ----.:......Phone --------- <br /> Address,,- _....c ;� f <br /> ---- - -- -----Cit _-Zip Nam e_._.. - License #.. - . <br /> .-Phone....................... i <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other........---- <br /> Number of living units:..... ... <br /> ,......Numb'er of bedroo _...: Garbage Grinder Lot Size------- .._ (, <br /> Water Supply: Public System andme"."" <br /> - <br /> Character of soil to a depth of 3 f -------------- ----------------Private Eleet: Sand ❑ ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan' <br /> ❑ 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 avi ilbble within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Liquid Depth. <br /> J [ Size............................•--------------------- <br /> Capacity------------- -----Type-----------....... Matarial-..-------••--_-- ------No. Compartments <br /> Distance to nearest: Well--........... ...............Foundation------ -- --.-...Prop. Line------------ <br /> LEACHING LINE F m{- - m_. ._ _ r _ _ i <br /> I 1 No. of Lines ._......................Length of each fine:_-- -`--------- <br /> - - ----�..__- "W- Total Length .. -----..- <br /> F ........................... <br /> 'D' Box-...........Type Filter Material....- -----Depth Filter:Material:...... .....---------------------------- -_ <br /> Distance to nearest: Well----------- ................Foundation.-----•---„ ......Property Property Line4_-.--------- ...'--- ---. <br /> SEEPAGE PIT ( f Depth...... .. .....Diameter.----------------...Number_ -----------------•----F.----- Rock Filled Yes ❑ No ❑ <br /> Water Table Qepth. .-:--Rock Size.. ..0.............. .......... <br /> : (� <br /> ti `N <br /> Distance to nearest: Well..--- ..........Foundation............. . .Prop. Line.------...-.------ <br /> . .-. _- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.. ....... Dat )- <br /> Septic Tank (Specify Requirements)-'__._'.._ � <br /> Disposal Field (Specify Re <br /> q.uirementsJ.... <br /> • <br /> ------------------ ... <br /> - (Draw existin and r <br /> g' equired addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son 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_work_for_which. this permit is issued, 1 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--------- -- --- l 1 <br /> ---------------- ---------------- <br /> Title..._.........� ­ <br /> Of other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.-•--- ---- -- --- - DATE ......... - . ' <br /> - - ........ <br /> DIVISION OF LAND NUMBER.................. DATE-.-...-----..-----• _ <br /> _ -- •.---- ---- - <br /> TIONAL COMMENTS... ............ <br /> ----- -------- ............................... ---- ....... --------- .... .... . <br />----...----" ---------------------------------------- a , <br /> --------------------------------- ---- ---- ------------ ---- ---- .............. <br /> ------ ----------- - <br /> Final Inspection by: ------------------ <br /> �- - - ---------------------------------------------Date.----------- z....... <br /> ---------- <br /> .- <br /> �... # <br /> --- - -------- --- ---------- ------- --------------------------- <br /> EH ZS 24 ��-- ---� - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />