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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------ <br /> -- <br /> --- ------------- - Permit No.7 <br /> --------------------- (Complete in Triplicate) -�r- -FS----- _ <br /> -------------- ---Y.I--- - -1 77 <br /> Date Issued- <br /> This Permit Expires t 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/LOCATION- /f -- ----------------------------------------- --------------------CENSUS TRACT- ---------------------------- <br /> Owner's Name----- - ----------------------------------------------------------------------------Phone------------------------------------- <br /> Address. ------- 5---- ---- --- - - ------ City ZiP----------------------------- <br /> n <br /> Contractor's Name--- �' �_------------------------License #3- 01171___--_Phone Il � <br /> Installation will serve: Residence❑ Apartment House 0 Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--------------------------- ---- <br /> Number of living units: __ ______Number of bedrooms--:5----- Grinder------------Lot Size-_ ---6-o/_�__1_ __. <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Q Size-__= .-A--h"�1D-------------------------Liquid Depth___'-__-_--____-____ <br /> _!-_v`Y <br /> Capacity _p- _Type-�+_----- ------/,Caterial----l_QIn----------No. Compartments----- -------------- <br /> Distance to nearest: Well_., ___________Foundation_-____-I_� ______,___Prop. Line_-__Lj _____-____ <br /> LEACHING LINE [ ] No. of Lines_.___'_--____-_______--Length of each line-------40--e�---------------Total Length _-_1_?0_____-___-_-__________ <br /> 'D' Box-----[------Type Filter Material_.-_-/ ---Depth Filter Material_-___ �_.-------------_----- <br /> - ----------___--- - <br /> Distance to nearest: Well---------------------------Foundation-- 7_2- --------------Property Line.---hr <br /> — r <br /> SEEPAGE PIT [ ] Depth-_-474__-__Diameter..-_51-._------- <br /> Number__.._ -------------------- Rock Filled YesAA No ❑ <br /> WaterTable Depth----------------= -----------/----------------------Rock Size--------- ------------------------------ <br /> Distance to nearest: Well ________Foundation_-_�a__._-_______Prop. Line--------------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__-________________________________________-Date.-___-_____________--_.---------------------- <br /> Septic <br /> ___-___- __Septic Tank (Specify Requirements)----------------------------------------------------------------------------------------- ...------------------------------------- -------- <br /> Disposal Field(Specify Requirements)- ------------------- ------ --------• ---------------------------------------------- <br /> -------------------------------------------------------------- ------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 become subject to Workman's Compensation laws of California." <br /> Signed---- ------- ------- --- Owner <br /> By------`G% --------- ----- ----------- ---------------_--------- Title----- ,. ---------------------------------- ---------------------------- <br /> (If other than own r) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------- ----------------------------------DATE_ X77--------------------- <br /> ------- -- -- -- -------------------- <br /> DIVISIONOF LAND NUMBER.----------------------------------------------------------------- ------------------------------ -----DATE---------------------------------------------- <br /> ADDITIONALCOMMENTS------ ------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---- ---------- -------- --------- ---------------------.�------- -- --------- ---------- ------- ---- --- ------- ---- -- - <br /> FinalInspection by--------- ----- --- -- - ------- -------- ------------ ------- ---------- - -----------Date- �--- - ---- ---------------------------- <br /> EH <br /> -- ----------- ------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M <br />