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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------- ---^ <br /> ------------ (Camplete,in Triplicate) Permit No..__ - 5 <br /> ------------------------------------ -------------------- <br /> i <br /> ` Date Issued----,7Z 7� <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 Ordinan No. 549 anA existing Rules a d Regulations: _ o <br /> r <br /> JOB ADDRESS/LOCATION--------- ------------ ---------- _.. ..CENSUS TRA <br /> CTi:___2 --- --- --- <br /> Owner's Name--- -------- - ---- - - --- - - ---------- ----- -------------------------- Phone. --------------------- <br /> Address <br /> ------------------ <br /> Address------------------ <br /> C <br /> --- = _... ._ _City __Zip <br /> - ----------------- ------------ <br /> Contractor's Name-------- --a License #__ 1, ' Phone.' _ 1�� <br /> Installation will serve: Residence ❑.. Apartment Hous ❑ Commercial ❑ Trailer Court ❑ <br /> ' .. x• 4. Motel ❑ Other- s� - --- ' - ------ [. <br /> Number of living units:----/----_-Number of bedrooms ---,----- Garbage Grinder------------Lot Size.-- - 7--- <br /> Water Supply: Public System and name--------------- - ---- -------.- -- ------------- - _----.- _-------Private [ <br /> = <br /> Character of soil to a depth of 3.feet: Sand Y❑ Silt❑ Clay [❑ : Peat Gandy Loam ❑ Clay Loam 0 <br /> r <br /> Hardpan ❑ Adobe ❑ Fill Material__..._�_._.._If yes, type_______________________;___--- <br /> (Plot <br /> -(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) o <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ } Size-----------------------------------------------------------LiquidDepth_T--------------------t--- <br /> Capacity- - ------- !:_:_+:-Type ----------------------Material--------------------------No. Compartments --- ----- <br /> . Distance'to nearest:.Well-----------------------------7-------------Foundation--------------------------Prop:"-Liner',"-- ------------------- r <br /> LEACHING <br /> -- --- <br /> LEACHING LINE [ ] No, of Lines-'-_---'- <br /> ! --- --Length of each line------------------------ ----------Total Length.--------`--------------------- ------------ <br /> D' <br /> - ------D' Box-- -.---Ty'le Filter Material------------- -----Depth Filter Material---------------------------------------------.------ -------. <br /> .r. <br /> t Distance to nearest: Well____________________________Foundation---.-_---------------------Property Line--"--------------- <br /> ..., _. . .T .; . <br /> SEEPAGE PIT [ ] Depth--------._�----Diameter.)------------------Number__________:______ ------------ Rock Filled Yes ❑ No ❑ <br /> Water Table-Depth---------------- =--------------------------------------- Rock Size------------ -------------------------------- <br /> ! Distance to nearest: Vi/ell -------------- -----------. ----Prop. L'.ine,----.- ------- <br /> REPAIR/ADDITION Prev. Sanitation Permit#------- ------------------_- _---_____ Date_ ation._. <br /> Se tic Tank (S eclf Requirements)-_ Y _--=-_- _.__` _.------------------- ------ �- -. -- - �r <br /> p P � Y . rq - � t `����� <br /> YG ---- <br /> Dispoos`al Field (Specify„ equirements)_,_ <br /> ------ 1 .cX ------- --------------- ---------.---- ----------- ----- ------ _ -. -.-. ---------------------------------- ----------------------------- --- <br /> =-------------=---------__-------- ---------- ------- =-------------------------------------------------------------------=------ ---- --- ------------------------- ----------.---------------------- <br /> (Draw existing and required addition on reverse side) . <br /> I hereby certify that ].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: ?!-ii.. ] <br /> "I certify that in the performance-of'the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become bject to;W,orkma As Compensation laws.:of California." }' <br /> Signed- �.._ - ---- <br /> ---- ----------- g i Owner s <br /> BY ` ' '. -[ii/ - = -.Title ------- <br /> -------------------------------- <br /> ---- <br /> ----- ------------------ <br /> I V (If ofh:" than'owner) 4 <br /> FOR DEPARTMENT-USE ONLY # <br /> APPLICATION ACCEPTED' BY= °. . M"---- M_` ------DATE.----�� ----- -- ------- --- <br /> DIVISION OF LAND NUMBER------------------------------ - r _ <br /> i= ----.DATE--------------------_------- ----- --------- <br /> ADDITIONAL COMMENTS ----------- - ----------------------- ---------------------------- <br /> ---------------------------------- i - - v_ ► ----------------------------------------------t---- <br /> F i <br /> --------------------------- -- <br /> Final Inspection by: L� = -` Date_ -3' y ----------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M ,r <br /> Y <br />