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FOR OFFICE USE: FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT . <br /> ---------------- <br /> 4-7/1-0 <br /> (Complete in Triplicate) Permit No.--7 -------,Z3------- <br /> Date <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../6 Fa <br /> CENSUS TRACT------------------------- <br /> p ---- --------- --Owner's Name.-------- - -- -------- --- . --Phone. ,7-1 �OF <br /> - -- --------- <br /> Address <br /> --------------- ------------ --- City - /-------- -- ------------ziP------------ <br /> -- - -- ------------ <br /> Contractor's Name.-------- - ­ --------------------- -- --- ----------------------------.License <br /> Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---- ------------- -------------- <br /> Number of living units:--- -/.---Number of bedrooms_._/----Garbage Grinder------------Lot Size---- a- ___-------------______ <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 ---------------Liquid Depth --.- --------------- <br /> [ ] Size -- ----------------------------------- <br /> Capacity---------------------Type ----------------------Material-------- ---- ------------No. Compartments---- . - -------------------------- <br /> Distance <br /> --- ---------------------Distance to nearest: Well-.-----------------------------------------Foundation------- -----..Prop. Line-----------------------_---. <br /> LEACHING LINE ( ] No, of Lines---------------------------- of each line-----------------------------Total Length --------- ----------------------------- <br /> 'D' Box.----.------Type Filter Material..------------------Depth Filter Material---------------------------------------------------------------- <br /> Distance to nearest: Well----------------------------Foundation----------------------------Property Line......-----------------------_-_---. <br /> SEEPAGE PIT [ ] Depth---------------.Diameter -----------Number-------------------------------- 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 /> Disposal Field (Specify Requirements)_____ _ Q--_/K - ----------------- - ----- 4 , -. �- 33 <br /> x r —-- 10, <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 ' ct t Work n's C mpensation laws of California." y. <br /> Signed =Etc, t <br /> g ------------------------- --------- -------Owner <br /> BY ; ---------Title------------ --------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .-. ---- -------------- --- 7-. <br /> DATE.- -.1.1r'y ----------------------- <br /> DIVISIONOF LAND NUMBER---------------- --------- ------ ----------------------------------------------------------- DATE ---- -------------------------------------- <br /> ADDITIONAL COMMENTS------- ------------- <-. -- } <br /> ------------------------------------------------ :-------------- ---- -----C-- -- <br /> ----- ------------- - <br /> -, 4-4-W-------------------------------------------------------------------------------- �------- -�-�------------------------------ -- ------ ----- ----------- �. <br /> ---------------------------------- ------- ----ik-S--rd 11-----ti �� p <br /> Final Inspection by:-- --Date ------ <br /> EH 13 24 USAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 776 inn 4 <br />