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FC}R OFFICE,USE: - FOR OFFICE; USE: <br /> f _ APPLICATION FOR SANITATION PERMIT <br /> s. .. <br /> -------- <br /> s . <br /> (Complete in Triplicate) Permit No.���.�f:.:. <br /> t <br /> • ..IDate <br /> •••-- .- •••-•---------------- ----- ---------. .... This Permit Expires l Year From Date Issued <br /> Application is hereby made to..'he San Joaquin Local Health District fora permit to construct.and install the work herein described. <br /> This application is made in complian with.County Ord' ante. No. 549 and exis Rule• nd Regulations:. <br /> .� ..CENSUS TRACT--- ----------.........._...... <br /> f JOB ADDRESS/LOCAT N..... I�' rL. � ... <br /> Owner's Name . �I - Phone.... -------- •.:..... ............. <br /> Address.......- .. .__ .. ._. l- .------ ....... ----City------------- ---------------- Zip <br /> Contractor's Name..... License #.- - F1111'7 _-Phone.? �.11/y7. . <br /> Installation will serve: Residence A artm nt House Commercial Trailer Court ❑ <br /> ❑ p ❑ ❑ <br /> Motel ❑ Ot r------------ --------------------------------- <br /> Number of living units:_.------1-.,::__Number of bedrooms..... ....:Garbage Grinder------------Lot Size----1p_eO-./ /. ------------------ - -- •- <br /> l� Private <br /> ` Water Supply: Public System aiyd name.- ..... ...:. . -- - ------•-•- - - ------------------- - --------------=-••------ � -• ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ -Cl.ay.❑—_Peat..❑ . Sandy Loam.❑.. Clay Loam ❑ ^ <br /> Hardpan ❑ Adobe ❑ , Fill Material.. .... ....If yes, type------------------------.-.--.- <br /> (Plot plan, showing size of Iot,!!!!!!locotion of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> i NEW INSTALLATION: (No septic tank or seepagepit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( } SEPTIC TANK [ ] Size ...-------- -------------------`.__t°........S=.-- _-......Liquid Depth---:....................:.. <br /> Capa city -... ..............Type ----------- --- -- Material-- ------------------------No. Compartments -------------- ............... <br /> Distance to nearest: Well--'.---------------------I... ........___--.Foundation------ ..Prop. Line.......-..----------........ <br /> - i; <br /> LEACHING LINE [ ] No, of` Lines _.... -------------- <br /> :--._.Length of each line ------- ----------------- --- Total Length .. .... ------ <br /> 'D' Bok --- - . ..Type Filter-Material........ . - -- Depth Filter Material--................ ...... . ------_ --------- <br /> Distance,to nearest: Well-- .......Foundation------------------------_.Property Line..........---- ---- ...... <br /> SEEPAGE PITII� <br /> [ ] Depth:>................Diameter':...............-..Number..-..--------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth----------- -------- - ....-------------------Rock Size----- .......---- ---------------•------ <br /> rDistance to nearest: Well---------------- -- - ---------..........Foundation--- ----..... --....Prop. Line------. --- --- ----------- <br /> Nil ,- . ..«,.d <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---•---------------- ---- ----- x�- ---------.Date------------------._.....--.--- --- 1 <br /> Septic Tank (Specify Requirements)-- -------------------- ` <br /> Disposal ield (Specify Requirements _ ... ... . _� - -. .... <br /> -.. <br /> ni <br /> -- ---------- - ------------------------ - - <br /> ` . . . <br /> ------------------------------------ ------------ ---------- ------ ---- _= - .A ------------••--•- ----- ......................_... -------- <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, andl1 Rules and Regulations of the Son 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 subject to Workmion's Compensation laws of California. <br /> Signed w <br /> .......0 , <br /> _ tleBY-•• -• - C - - -- - ... ------------ --- - ----- ---- ------------- <br /> ( hI ot (u;r nwner) <br /> 9 FOR D PARTMENT aaSEONLY <br /> APPLICATION ACCEPTED BY-i!l---.... ...... <br /> .!!- 2 J-- ------- --------------- DATE ..7 _Z ._� . . <br /> DIVISION Of LAND NUMBER-------- ---- --- DATE......-.... <br /> ADDITIONAL COMMENTS...---1I...... - ..... .6. <br /> ............ .............................. -- --------------...._------------------- ----.....-- = <br /> - h- ---.- _ --=-------------------------------.....;...------------- ------.._ ...._-....... <br /> Final Inspection b--y; .._.. -.-r ----------------- --------------------------------- ....Date.----- ---- .. . <br /> EH 13 24 SA JOAQUIN LOCAL HEALTH _DISTRICT F&S 21677 REV, 7/76 3M <br /> __f <br />