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FOR OFFICE USE: 4? FOR OFFICE USE: <br /> APPLICATION FOR"SANITATION PERMIT <br /> -------- -------------- - <br /> ------- ------ -- Permit No...... <br /> (Complete in Triplicate) <br /> ------------------- ----------------- ------------------- <br /> Date �- 77 <br /> Date Issued-' ------ <br /> ---------------- ---------­___ ----------------- <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. 549andexisting Rules and Regulations: <br /> Z11 41 <br /> JOB ADDRESS/LOCATION------------------ ._l / CENSUS TRACT - <br /> Owner's Name.-------- � - ------------------------------------------- --------1­- ------------------- -- ------------Phone -g4v <br /> Address------------------------�' N -- ---- --�-------- ----- ----- ----- ---- -icitY-- . -----zip------------------------------ <br /> Contractor's <br /> ------ -� - <br /> Contractor's Name------- i ----- <br /> A ------------ ---- -------- I-License # J� fPhone1� <br /> Installation will serve: Residence;[ Apartment House.❑ Corrimercial ❑ Trailer Court .❑ <br /> 4 Motel ❑ Other---------------- ----------------------------- <br /> ----- <br /> ------------- - <br /> Number of living units:__:.__-___._ _Number of bedrooms._-----Garbage Grinder-- Size----_.._p�.'_ __________ _______________ _______________ <br /> Water Supply: Public System and name--------------- -------------------------------:----- ------------------------------------------ Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam V 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 pub(tc sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] t SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth--------------------------- <br /> -- ---Type.. •-------Material---------------- - No. Compartments. •� <br /> Distance to n ears#:_Well.., __ _ ._ `_---Foundation--------------------------Prop. Line------------------------jr <br /> - t - �E <br /> LEACHING LINE [ ] - No:t of Lines---------------------------y-Length of each line°--------------------------.Total Length.------------------------ ------------y <br /> DBo)t"---------fType Filter Materials------- --------Depth Filter Material_______________________ <br /> Distcince to nearest: Well----------------------------Foundation----------------------------Property Line-.--------------------------------ni <br /> SEEPAGE PIT ] ] Depth-----------------Diameter_.._.-_.------____-_Number_-------- ___________ Rock Filled Yes ❑ No <br /> WQr Table Depth Rock Size------------------------------------------------ <br /> C <br /> � t G <br /> Dista ze to nearest:yell--------------------------------------------Foundation Prop. Line <br /> REPAIR/ADDITION (Prev.i SaMtotion Perm:it#=------------------------------------------------i-Date....- ------------ ------------------) . <br /> Septic Tank (Specify Requirements)----- —---------- .----.----------------=T-----------;---- ------------------ -------- ------------------------ -------------- <br /> ;4, . <br /> Disposal Field (Specify Requirements) .... ............ , --------------------------------------- <br /> ] i -. ------`- ---------------- ---------- - ------------- <br /> - - ------------------- <br /> } r -- ----------- ------------------------------------------- <br /> ----------------------------------------------------------------------------------------- t----------------- ---- --s------------------------- <br /> (Draw <br /> --- - ---- <br /> (Draw existing and required addition on.reverse side) <br /> 1 hereby certify that 1 have prepared,this application and thaL thew.ork will be clone 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 <br /> "I certify that in the perfo mance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to rkr7s. Co nsation laws of California." f <br /> Signed._- s '----- ...w- ner... <br /> Ow t <br /> Title ------------------- <br /> (If other. than.owner). "`" 1 _ -6. --- -- -- - r' <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- ------- - ------------------ ---DATE.--- ---- ----- <br /> DIVISIONOF LAND NUMBER----------------------------- --------------DATE----------- -------------------------- ---- ---- <br /> ADDITIONALCOMMENTS ------------------------ --- ----------- ------------------------------------------------------------------------------------------------------------------ <br /> ---------------------=---------------- ----------- -------------------------------------------------------- <br /> ------ ----------------------------------- - ------ <br /> Final Inspection 6Y ---------._Date----- - ------- <br /> EH 13 24 SAN JOAQU LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M <br />