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`(OR OFFICE.-USE: FOR OFFICE USE: <br /> APPLICATION FOR-SANITATION PERMIT <br /> ----------------------- ------- - <br /> {Complete in Triplicate} Permit No___________________ <br /> This Permit Expires 1 Year From Date Issued Date Issued------ �_r 7� , <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/LOCA ON ` = � v- -- -- ---------•--- CENSUS TRACT-------------------------------- <br /> Owner's <br /> ------------ ------ r <br /> Owner's Name -. = Phone <br /> '� ------------------ ---------------=--- � <br /> Address__3�96------------ Ci Zi <br /> - . . -----..... . -------< <br /> - P <br /> Contractor's Name-''.- _'__.._- _- 47 <br /> _____.-..__.License #--t `_7� .- �-- __Phone_y6. _ �� <br /> --------------------- ---------- <br /> Installation will serve:" t Residence Ire Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> + `Motel±❑ - Other---,---- <br /> o living :t"" /t sr of bedrooms_---_�. <br /> ._.Garb�aga Gri'nder_� Lot,Size_,��4, .X...:: :/---------------------------- <br /> Water <br /> .�... <br /> ........... _-.___-._._ <br /> Waer SuppIY. Public System and name ____-_:.___-_._.-;.....:.------------ ----- ------------------------------------------------------ <br /> �._. <br /> ,i <br /> ------Private ElCharacter of soil to a depth of 3 feet:) Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> i Hardpan ❑t 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 INSTALLATIONS ' (No,septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ j "SEPTIC TANK [ I Size-------------------'--------------------------------------_Liquid Depth._------------------------_ <br /> �-- Capacity. t ------ Type .----------------=----Material---`------ ---- - ---No. Compartments-------------------- -.------ . <br /> '. Distance to.nearest:.Well,..... - ---Foundation ----------- :---.Prop. Line--- ----------------- ------ <br /> LEACHING-LINE' <br /> - --LEACHINGLINE' [ ].... No. of Lines.,) -:-4v----------------Length-of each line..-.. ., ---------Total Length.--------- - -. ---- <br /> i C <br /> D' Box--- -- TYpe.Filter Material.--= Depth Filter Material ---------------- r - -. <br /> ' .. <br /> Distance to nearest: Well--------------�-----------Foundation_ .- Property � '--- <br /> -Pro er Line______________ <br /> SEEPAGE PIT [ ] Depth-------.--- __.Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Rock Size________________ <br /> Water Table ' <br /> Depth----------------------- ------=-------------:------ ------------------ <br /> Distance to nearest: Well---------------'----..-------------------'Foundation-------------------__-'-.Prop. Line--------------------------- <br /> --------------------- <br /> REPAIR/ADDITION -----------------------------:Date--- ---------------_- .� -.._. _ �._.). 4 <br /> REPAIR ADDITION (Prev. Sanitation Permit#_______________�_.__ .____._..__.__.- a <br /> k <br /> Septic Tank (Specify Requirements)---- I - - ; <br /> Disposdl Field.(Specify Requirements)-- d - ------ - ------------------ <br /> -------- <br /> r ,... ,�. ._,.. <br /> - --------------------------- -- -----=-.------------------------------------------------------------------------------ -- ----------- - -------------- - <br /> --------------------------------------- ---------------- -------------------- - ---------------------------------------------------------- ------------- ---------------------------- <br /> (Dr <br /> a aw existing dnd required addition on reverse side) ` <br /> I hereby certify that 1 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 becoblect to rkman' Compensation laws -of California." <br /> Signed- ----- =- ------------------Owners ' <br /> .- . <br /> By- -`--------- , -°---------------------Title <br /> 11( <br /> t � (If other than.ow er) <br /> FQR4DEPARYMENT USE - L i <br /> APPLICATION ACCEPTED BY ---- - -------------=---DATE - ---- '`� - <br /> DIVISION OF LAND NUMBER -- ------ ----- - ------------ DA <br /> ---------- QATE <br /> ADDITIONAL COMMENTS-------------------- --- --- - -- --------------------------------------- ---------------------------------------------------=-------- <br /> -------------------------------- ------ - -- ------------------------------- -----------------------------'-- ------------------------------------------ <br /> --------------- <br /> Final Inspection bye, = Date ----------- <br /> EH 1324 SAN J0AQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />