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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.?e'It�/-..___ <br /> --------------------------------------------------------- <br /> Date Issued_/1 <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 N . 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC9I10N----,---------------- -- - <br /> -----CENSUS TRACT-----------------------------Oel— <br /> --- <br /> JOB <br /> Name � / „� ' ------------------------------------------ ----- -- -------- ------ <br /> Address-.-. <br /> ---- Phone ------------------------------ <br /> Owner's <br /> Address- ---------------1___Z3 _ <., ��� ---------------Ci tY - ----- ----- --- ------------Zip------5- --- - <br /> Contractor's Name____ _ _ _ - ___ -- `� "'Z `` ------ <br /> �1� ------ ---------------- -------------------License #_ 0' - Phone = <br /> Installation will serve: ResidenceX Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------------ --- --------------- <br /> Number of living units:--- -------Number of bedrooms------ Grinder_._---____Lot Size_CG?//_S___'_ f<� U <br /> Water Supply: Public System and name-----------------------------------tz�---1 -4�- _: -----------------------------------------------------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 /> 1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth-_______-__-_____-_____5 <br /> Capacity---------------------Type-----------------------Material------------------------No. Compartments-----------------------------------` <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 O 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#----------------------------------__----____i- ---.D`ate -_._;_____ _____-.____________-._-) <br /> Septic Tank (Specify Requirements) --.----- --------- <br /> Disposal <br /> -- �� <br /> -�-- -- ----- ---------------------------------- <br /> Disposal Field(Specify Requirements)----- ---- ' p ---- - ------------------------------------------- <br /> ------------------------------------------------------- -------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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,.snlgject to Workman's Compensation laws of California.” <br /> Signed----- - - -- ------ ----------Owner <br /> - -- -- --- -- - - <br /> By------ ----------------------------------------------- / �'� " r�--------.Title---------- <br /> (If other than owner) <br /> lt PEPARTM,RNT,USE QNLY <br /> APPLICATION ACCEPTED BY________ __ _/tp_ _ - - -----^- ___ __ _ --------------------------------DATE -----f / _ <br /> DIVISIONOF LAND NUMBER------------------------- ---------------------------- --------------------DATE------------------------------------------------ <br /> ADDITIONALCOMMENTS------------- ---------------------------------------------------------------------------------- ----- --------- --------------------------------- <br /> ----------- ------------------------------- -------------------- ---------------------------------------- ------------------------------------------------------------------ <br /> ---------- <br /> ------------------------------------------------ =--- ------ --- -------- ---- ----------- ------ ----------------------------------------------------------------- - ------------- <br /> Final Inspection by:-------------- --- -- - ----- - -- ----------------------------------------------------------Date--- � -------------- <br /> r <br /> EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 3M <br />