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�zro <br /> FOR OFFICE.USE: . I FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT -/ 7- a � <br /> ---------------------------------- -------- (Complete in Triplicate) Permit No.__.-------- <br /> --____-- <br /> ------ ------------------------------ --------- --------- Date Issued__;7 _77 <br /> �3 ' 7 <br /> This Permit Expires 1 Year From Df" <br /> Application is hereby made to the San Joaquin Local Health District for a permit to con trust and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LpC,qTION _ - j' -- --- ----------- ------- -------- ------CENSUS TRACT- -. ----_. <br /> Owner's -------------------------------------------------------------------------------------Phone ----- '-------- <br /> ,rll_ -- - city------54 ---------------------Zip--- -------- <br /> Contractor's Name -----_Phone---4:? "�=---- <br /> :' <br /> Installation will serve: ,;,, Residence s'' Ap6firx4nt Ho a �-Qrrlmercial ❑ Trailer Court ❑ <br /> mss. <br /> Motel�Eo] " l�e�r - -� ---Number of living units:__ - Numbgr o_. <5G ler ----------------- <br /> ----------------------------- - <br /> Water Supply: Public System and name------------------------ .___""'_. __%____ _--'� Private <br /> ---- .Y,,.'..` -------- <br /> Character of soil to a deith of 3 feet: Sand ] Silt Clay ❑ Peat❑ Sandy Loam Ldbm ❑ <br /> iardpan ❑ d FiI Material If# %' e 3 `tea-.------ <br /> (Plot plan, showing size 6f lot, location of system in ration to wells, buildir+ sj etc. mus4e placed on reverse side) <br /> g e <br /> NEW INSTALLATION: o septic an or seepage pit permitted if public sewer is available within 200 feet,)i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------- ---------------------------Liquid De t� <br /> Capacity---- ----------------Type-----------------------Material-------------- -----------No. Compartments------------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line_____..__.___-__-.________ <br /> LEACHING LINE [ ] No. of Lines --__ _____ .Len th of each line----------, ------Total Length -- _ ---------- <br /> 'D' Box __ Type Filter Material ____ __ .Depth <br /> Distance to nearest: Well----------------------------Foundation__ __.___ ___-_--Property Line----------------------- <br /> SEEPAGE <br /> _..____ _________SEEPAGE PIT [ ] Depth----------.----.Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Well-------------------------------------------Foundation-------------------------.Prop. Line-..------------------------. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__-----------------------------------------------Date.__________________________--.______--------) <br /> SepticTank (Specify Requirements)----------------- ------------------------------------------------------------------------------------------------------------- -------------- --------- <br /> Disposal Field(Specify Requirements)----- ------- ------ --- _4 _4------- <br /> -`----- -- ----------------------------------------------------------------------- - ------------------------------------------------------- <br /> --------------------------------------------------------------------- <br /> (Draw existing and required additionlorTverse/Iside) <br /> 1 hereby certify that 1 have prepared this application and that the work wilJf doe in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Lolth District, Home owner or licensed agents <br /> signature certifies the following: t f =f <br /> "I certify that in the performance of the work for which this permit is issued, I shall a employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." F <br /> Signed - ----------------------------------------Owner ! <br /> 9 �Z /7 <br /> By----------------- °• - --) -----------------------------------Title---1 lr4 ,k----- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ ------- --- ------ -------------------------------------- - <br /> -----------------------------------DATE..-3 --Z - ----- --------------------- <br /> DIVISIONOF LAND NUMBER---------- -----------------------------------------------------------------DATE--------- -------------------------- ----------- <br /> ADDITIONALCOMMENTS------------------------------------------ -------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ----------------------------------- <br /> -------------------------------- -- ---- - --- --------- --- - --------------- - - --- ------ -- - - ------- <br /> Final Inspection by -- --- - ---- --- - --- - ------ ------ --Date ��� - <br /> EH 13 24 $AN�N LOCAL HEALTH DISTRICT <br /> - - F&5 21677 REV. 7/76 3M <br />