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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ........•-----•----------- --- -- .. 0- _---_ ��' �� <br /> tt ' � (Complete in Triplicate) Permit No <br /> {c� -------------- Q <br /> Date Issue ._" /..'.x� <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 rd' once No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.....' -. _CENSUS TRACT.....- <br /> Owner's Name.-_ ...- .... . .........Phone__.................... <br /> Address------ ��/� ­0 Ci ................................... .zip--• •-- ------------ ----- <br /> Contractor's Name__._ . <br /> ------ --------License # t (1/ / - Phone-- <br /> Installation will serve: Residence Apartment Ffouse ❑ Commercial ❑ Trailer Court ❑ <br /> Mtel ❑ Other---- ---------- -------.-..-_------ <br /> Number of living units:.----./---------Number of bedrooms... ._Garbage Grinder............Lot Size.--. ._. <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,) 0- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size......-------- ________________________________ Liquid Depth.....__..._...._--...--.- <br /> Capacity- - --- ----- -------Type-- •--------- ------Material----------................No. Compartments -•--- •---•--•--------.-..-.---- <br /> Distance to nearest: Well.....--.. -------- ---------Foundation------- -- - ---_ ._....Prop. Line............_.......... <br /> ... <br /> LEACHING LINE [ ] No. of Lines ...........................Length of each line.............................-Total Length _ -------------- <br /> 'D' Box............Type Filter Material......._..-..--.--.Depth Filter Material---------------------------------------- .-----� <br /> Distance to nearest: Well./..�'C.._..........Foundation--_--_---.--.-_-- ...Property Line.......... .-._-.-.� <br /> SEEPAGE PIT [ ] Depth..--------_...-Diameter--------------------Number-_.............................. Rock Filled Yes ❑ No❑ <br /> WaterTable Depth._-------------------------------- -------------•.......Rock Size-------------..------------------ ------ <br /> Distance to nearest: WeIL_--------................................Foundation.- ..............Prop. Line_........................ <br /> REPAIR/ADDITION (Prev. Sanitation Permit .:................ ............. �` ----- -.-.Date...................--___--------_.---_-_-) <br /> Septic Tank (Specify Requirements)-_-__. ... _ �s-� -------��/ ... -----------*------- <br /> Disposal <br /> ----Disposal Field (Specify Requirements)..... �..�__ _ --------------- <br /> ------------- ----------- tl ---------------t---- ----- .. <br /> L <br /> -.-._...... -- ---------- ------ '72• .... --- ..-.../� . .1� -------- <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, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed........ ., --- ---- - ---------------------------- - ------ ner 4_�F_ <br /> By....... ' ...- ......Title.--- ---•------------ ------- ------- -- -------------- -- ...... <br /> If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.... DATE__.A. AL-�.�._..... <br /> DIVISION OF LAND NUMBER(.. - -------------------------------- •---- DATE ----------- .............. ---- <br /> ADDITIONAL COMMENTS..........---------...._.---- - -- -----.. <br /> -----•-------------------- -•--- -- --- --------------...-- --- . ---------....... --------------- ----------------.............---•-----• ---------••------ ............................. <br /> --------------------- ----------- --- -....----- ........................ ...._..----------..... --•--------- ...........................----- .................. -------------------------_... <br /> - �� �q <br /> . <br /> 4` <br /> Final Inspection by:._ Date------------------ --- . . . <br /> - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fss 2ian REV. Ana 3M <br />