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FOR OFFICE USE: � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERNK <br /> - - - - - - - Permit <br /> (Complete in Triplicate) <br /> -----"_ -t Date Issued--P- '�7y <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 /> 'r^ ,D "_ --- -- <br /> JOB ADDRESS/LOCATION - -- -�t -a - : �� - � CENSUS TRACT � ��• <br /> r� , <br /> CI p �C <br /> Phone �, <br /> F <br /> Owner's Name. y --------- <br /> IV --- ---- --Zip .. --- - -- <br /> ----- <br /> `/ - City_f <br /> Address - -- <br /> Contractor's <br /> - <br /> - Sz ej <br /> - <br /> Contractor s Name __ _ __..__._License #_- - Phone� <br /> Installation will serve: Residence% Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------ ------------ ------ - ----- ---------- <br /> Number <br /> --------Number of living units:."- --- ------Number of bedrooms---Z,_ Garbage Grinder---_---"---Lot Size------.-l----= -- - <br /> Private <br /> Water Supply: Public System and name---------------- --- --------------- <br /> -------------------- <br /> ----------------------- <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,) �� r <br /> Size - ----------Liquid Depth- ------ ---- ----- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] - <br /> ��ss�� ' No. Compartments <br /> ' ----------.-, -- <br /> CapacitY�`���- - TYpe - �� - C'�'�� �Mate�rial - - p <br /> 01 <br /> --------- Prop. Line <br /> _� Foundation " - <br /> Distance to nearest: Well__ �_�_---"--------------------- <br /> ` __ - <br /> �'- '`.--- _Total Length -- ----- ---- ---------- ------------ <br /> LEACHING LINE [ ] No. of Lines--__ ---------- ---- Length of each line -_- r y g <br /> D' Box- Type Filter Material- -X L� Depth Filter Material____.C__________ ----------- <br /> Distanceto nearest: Well__ �'�- --------- --Foundation_-" ��-- -_�-"__-_Property Line-_ .. - ----- <br /> SEEPAGE PIT [ ] Depth-__ -Diameter------___-"- ---Number------------ ------ ------------ <br /> Water <br /> --__ Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth---------------- ----------- ---- - --- -------------- Rock Size--------------- ---------------------- <br /> Distance to nearest: Well- ------- ----------- ------------------Foundation ------- -- - ------ -" Prop. Line.---- - ----------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#___--__---__---_._----------------------------Date-_- --------__{---------------------------- -) <br /> Septic Tank (Specify Requirements)-- - -- - - ----- ---------------------------- ------------ - - - - - <br /> ---- -------------------- <br /> Disposal Field (Specify Requirements)-------------------- - -._"--_----- - - --------- --- <br /> -------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------- <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 /> "1 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---,fF7- t -- - --------- <br /> --- --- --- ---Owner <br /> - - -- <br /> BY-- C•` G �`""/------------------- ------ ------ ------ - - -Title - - - - - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 17"APPLICATION ACCEPTED BY--------- -` -- ------------------------ ----------- ----DATE ------ I - 7-r- ----------- - <br /> DIVISION OF LAND NUMBER - --- - ---------------------------------- --- ----- ------ DATE ------ --- - - ---------- ------ ----- ---- <br /> ADDITIONALCOMMENTS- ---- - ------- ----------- ------ ----------------------------------------------- -------- -- -------------------------------- ---- ----------------- --- - ----- <br /> ------------I--------------------------------------------------------- ----------------------------- ----------------------------------------------I-------------- --------- - ---------- ------------------------ <br /> --------------------------- ------ ---------------------- ---- ------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------- <br /> c ------- -------- ` -- <br /> ------ ---------- <br /> ---- ------ ---- - ---------------- ------------------------ <br /> - ---------- -- <br /> Inspection b - - - Date <br /> P Y:--------- t �. ? ------------------- / ----------------- <br /> Final <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />