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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------I--------. (Complete in Triplicate) Permit No._7j7' <br /> 5-77 <br /> Date Issued--_ffY.._ ___________ <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/LOCA oL-5 �t l - --------------CENSUS TRACT---------------- ---- <br /> Owner's Name-------- !1/� -- -- -----------Phone--------------------- <br /> Address <br /> ------------------- <br /> Y <br /> Address------------------ --- ��r `—�.----- - ------- -- ----- -- City- - ---------------------------Zip----------------------------- <br /> ` 5 Z �Zz <br /> Name---------- - - License # - -------- <br /> Contractor's Phone <br /> de <br /> Installation will serve: Residence[1r Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------ -----------------------.- <br /> Number of living units:------- ------Number of bedrooms___...1_---.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 availcrble within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth---------_.___.__.__.._-- <br /> Capacity--- ------------TYPe----------------------Material--------------------------No. Compartments----------------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line_____._______-_.---------_(� <br /> LEACHING LINE [ J No. of Lines---------------------------- Length of each line-------------------------------Total Length---------------------------------------- <br /> 'D' <br /> ______--__________-.__.________._.--_'D' Box-----------_Type Filter Material--------------------Depth Filter Material---------------------------------------------------------------- <br /> Distance to nearest: Well ____________________..___Foundation----------------------------Property Line----------------------------------- <br /> 'Q <br /> SEEPAGE PIT [ ] Depth----------------Diameter____-._--.____---.Number-____:_r--.._________._____--- Rock Filled Yes ❑ No ❑� <br /> WaterTable Depth---------------------------------------------------------Rock Size----------------- ------------------------------ V, <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 /> --------- <br /> z -- ----------- <br /> ----------------------------------- ----------------------------------------------- ------------------ <br /> (Draw existingand required addition on reverse side) <br /> I hereby certify that l_uaxe 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------------------------------------------ -: --- Owner <br /> p ----- ---------------------------------- <br /> BY------------------------------------------------ -��'�---�--d%�� �------Title__� �c,.�'-eo�i� <br /> (If other than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ----C. ' ------------------------------------------- -------------------DATE.-/Q --- - ------------ ------ <br /> DIVISIONOF LAND NUMBER_----------- ------- -- --------------------------------------------------------------------- DATE------------------------------------------------ <br /> ADDITIONAL <br /> ------------------- -- -- <br /> ADDITIONALCOMMENTS---------------- ----------------------------------------------------------------------------------------------------- ---------------- -------------- <br /> -------------------------------------------------------------------=--------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- --- - ----- --- - <br /> ------------ <br /> ----------- <br /> Final Inspection bY:-----C_-'- -------- . _. Datef -• <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M <br />