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FOR OFFICE USE: FOR OFFICE USE: <br /> ,ONPPLICATION FOR SANITATION PERMIT <br /> \ (Complete in Triplicate) Permit <br /> Date Issued_f�r-_7 <br /> ---------- ---------------------------------------------- This Permit Expires 1 Year From Date Issued <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 /> JOB ADDRESS/L� ION---"T ------ C� ' `"�'"'�'q- -------------------------CENSUS TRACT-------------------------------- <br /> Owner's Name___.__ _. ____ _ <br /> ------ -------- . ---------------------------------------------------------------------------------- Phone-------------------------------------- <br /> Address r 4----- =: -. , ----- ------------------------City --- " cse�------ -----Zip------------------------------ <br /> Contractor's Name------------ -- --------------------------------License #---------- ---------------Phone--------------- <br /> Installation will serve: sidence [Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------- ----------------------------- <br /> Number of living units:---._ --------- <br /> Number of bedrooms_.,�----Garbage Grinder------------Lot Size____________________._____..____________.___________--- <br /> WaterSupply: Public System and name---------------------------------------------------------------------------------------------- -----------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ O <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 [ ] SEPTIC TANK <br /> [ l Size----=-=-----------------------------------------------------Liquid Depth.----------------------- <br /> Capacity---------------------TYPe-----------------------Material-------------------------No. Compartments----------------------------------- <br /> Distance to nearest: Well_______________________________________-Foundation_______________--_____Prop. Line_____.____________________ <br /> LEACHING LINE [ ] No. of Lines-----------------------------Length of each line._______________.____-___-.Total Length---------------------------------------- <br /> 'D' <br /> _________________ -.-.____ <br /> 'D' Box_ Type Filter Material--------------------Depth Filter Material_____________________________________________________________ <br /> Distance to nearest: WelL_.-___ -______Foundation__________________________-Property Line__-______________--__.__-_____ <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) �,,,�f n --------------------- --`-----------•--------------------------------------------------------------------- <br /> -- --- -------�- --= _-`-----------=-!w=-`^- -------'-----------``--`----�----�--„-------I�--'"r--/ `- <br /> -- ------------------------------------------------------------------------------------------- <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 work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject Workman' Crnpensation laws of California.” <br /> Signed__ - ---------------------------------------------------Owner <br /> By----------------- --- -------------------------------------------------------------------Title----------------•------ ------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- �-"---- - ------------------------------DATE.-F- --. --- ---------------------------- <br /> ---- --- ----------------------------- <br /> DIVISION OF LAND NUMBER. ---------- ------------------------------------------- ----------------- DATE---- ---------------------------- <br /> -------------- <br /> ADDITIONAL COMMENTS------------------ <br /> --------------------------------------- <br /> -------------------------- ---------- -------------------------- ------------------------------------,------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------- ------------------------------------- -------------------••----------------------------------------------------- <br /> --------------------------------------------------------------------------------- ------ <br /> - ------- ------------ ----------------------- <br /> Final Inspection by:------- ` --------------------------------- --Date--.-� <br /> l <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3776 <br />