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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- 1 . <br /> (Complete in Triplicate) Permit No...7 .._a).__.. <br /> Date Issued..._.a.".....,2/"_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 Qrdinance No. 549 and existing Rules and Regulations: <br /> � - <br /> JOB ADDRESS/LOCATION .-._--- ---_....__._.. -- --------------- ------- ------------•- -.. CENSUS TRACT.._.......----.--.._.----.._... <br /> l-- <br /> Owner's Name.. . ..... Phone. -----------­---t- <br /> -- ------- -- ...... -• - ----- ---- - --- ------ -- . <br /> --- ------- <br /> Address.---------- - _.Cit Zi <br /> Contractor's Name_- -__ <br /> --.-.---. _.. -- - .......... ------.License #- --- -._ - ._.Phone__.._.-------------- <br /> Installation will serve: Residence ❑ Apartment Hou <br /> s ❑ Co mercial ❑ Trailer Court ❑ <br /> E]Motel Other_.... .1ZX" <br /> Number of living units:---------.......Number of bedrooms......_ _ Garbage Grinder------------Lot Size--- <br /> -. . _ ._-.____ <br /> Water Supply: Public System and name_ - -- ----- ---------- ------••-----------------......_........._. ..___... ----------..-.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <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,) Pr <br /> PACKAGE TREATMENT ( j SEPT Taj ( j ize .. ____ -._ _ '______________________..___.-Liquid Depth ----- <br /> Capacity-...._ _._.-......Type---k ....Material-.C- - -----.:No. Compartments----------------------------..-- <br /> � f- <br /> o / <br /> Distance to nearest: Well........ d_f`_..... . Foundation.....lb. _ ___Prop. Line..._.................. <br /> LEACHING LINE [ ] Na. of Lines ._.. _.1................Length a ch line_.._ ...__.._____..__Total Length <br /> ci <br /> 'D' Box--_c/Type Filter Material._ ___.._. ....Depth Filter Material_._.. ..--_ ..__ ....._------- ._-..____---_--.._. <br /> / r <br /> Distance to nearest: Well--- �_.__.�..._------Foundation. `.----------Property Line......_. _ ._._................ <br /> SEEPAGE PIT [ ] Depth.__-...__.__Diameter------.------- -----Number_------------------------------ Rock Filled Yes ❑ No❑ <br /> Water Table Depth.--------_--- --•------- - - -- --------_..........Rock Size..... .... ..------ ----- ----------- <br /> Distance to nearest: Well._--------------___-------------- .....Foundation------------._. .. ._...Prop. Line.........__..___...__..._ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...._.._...._..___.__........... ------.........Date.-------------------------------- -----) <br /> Septic Tank (Specify Requirements)---- ---- -••---------------- ------------ ------- _ ------ -- ----- ---. <br /> Disposal Field (Specify Requirements)..--- ----------------- ---------------------- <br /> ....-------•-----------•-- - ----- --------•._..------- - --- ----- ----..._......_ ------ ------------- -------------------••-•--__................ ............... .... - ----• --------- ............... <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 to Workman's Compensation laws of California." <br /> Signed------ -- . ./ - • <br /> ---- .......... -----Owner <br /> By.. -- �.. .._... _ <br /> ( <br /> r than owner) <br /> FOR DEPARTMENT E ONLY <br /> APPLICATION ACCEPTED BY_J - ----------- DATE .... _...... <br /> . <br /> DIVISION OF LAND NUMBER.._.--._-_- -- -- ------------- -----------------_ DATE ---------.. <br /> ADDITIONAL COMMENTS__............ ..._..... - - - - <br /> ---------- -----------_ -- ----------- ......... - ----- -------------- -- -------------- -- .......... ..... <br /> ---------------- ------------ - ---------- --- - -----.-C..------ <br /> ----------------------- ------------ <br /> Final Inspection b f . Date__ .__` _ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ass 21677 REV. 7/76 3M <br />