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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � � <br /> ----------------- ---------- ` Permit No. f <br /> (Complete in Triplicate) <br /> ------------ ---A ---- - Date Issued_o;L.-�� <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/LOCATION------1� 01�------r�' -----/GFS-------- <br /> --------------------CENSUS TRACT------------------------------- <br /> Owner's Name------------lsPhone <br /> Address------------------- -- --------- <br /> ---- <br /> - city zip <br /> Contractor's Name_------- ------ ------- - License # ?J Z 20� Phone <br /> Installation will serve: Residence[Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------------------------- ------- -------- <br /> Number of living units:-----._.1_.---Number of bedrooms-----'/__Garbage Grinder------------Lot Size________3.r-d__ __________._._____---___ <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 gj�e' 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 see age pit permitted if public sewer isa vailable within 200 feet,) / 1Z <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size__?r_---- _________________________Liquid Depth____---------------- � <br /> 1 <br /> Capacity-/4d,_0------Type.- _ Material------(C-z- ----No. Compartments--------?------------.--------- <br /> Distance to nearest: Well-______._ _----------------------Foundation-------s <br /> --- Line------ <br /> LEACHING LINE ()/1 No. of Lines___________ ___________ Length of each lin- _______4/ _ <br /> Q--_________.Total Length.___./_�,d__--_____ _____________ <br /> 3- _ __ <br /> 'D' Box------/----Type Filter Material-_ ___ <br /> -_ A______Depth Filter Material---------,l_f_M---------------------------------------------- <br /> i <br /> Distance to nearest: Well t4___1�Q____---__.Foundation___.__/.2)__f____________Property Line__________.--_____________. . <br /> it <br /> SEEPAGE PIT [ Depth--- -_-rP"ADiameter_____��-___ Number---------------7-------------- Rock Filled Yes No <br /> Water Table Depth---------------- --------f----------------Rock Size--- --....---------- <br /> Distance to nearest: Well. ------------------Foundation--------I._10._1---------Prop. Line.------ ______-__. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#___________________________________________________Date__________________._..-___.__________._ <br /> -----) <br /> SepticTank (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, 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--------------------------- lr'#' ---Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- --- - ---- - - - - DATE <br /> -- --- --- -------------- <br /> DIVISIONOF LAND NUMBER.- ---------­_­___ ----- ---------17------------------------------------------------------ ------------DATE--- -------- ---•--------------------------- - <br /> ADDITIONALCOMMENTS----------------------- --------------------------------------------------------------------------------- ------------------------ <br /> -------------------------------- ------------ ------------ -------------------------------------------------------- --------------------------------------------------- ------------------------- ---------------- <br /> ------------------------ -------------------------------------- ----•---------------------------------------------------------------------------------------------------------------,------------------------- <br /> ------------------------------------ ------------- ` <br /> �. _ �'-J - <br /> Final Inspection bY:-----------/--- - ---- -------�� `-'f ----------Date------- -----------------------�-------,- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M <br />