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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> _______ __ Permit No.-�g_`��--��---� 4 <br /> -------- <br /> - (Complete in Triplicate) <br /> ----------------------------------------------------------------------- Date Issued__ -_ " <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 /> CENSUS TRACT------ -------- <br /> i <br /> JOB ADDRESS/LOCATI � ------ <br /> Phone------- -- ------------ ------:--- <br /> Owner's Name.---------- - --- - 1.444 -- ------------- --- - ---- <br /> Address - , - ..-- City ------------------------------ <br /> Address <br /> ---- ------------------------ <br /> / 4 <br /> Contractor's Name------- License #__ � "Phone:._____--------------- --------- <br /> Contractor <br /> . <br /> will serve: Residence Arpartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Installation <br /> Motel ❑ Other---- ------------------------ <br /> t __-_-Garbage.Grinder----__.----_Lot Size---------------------------------` `---------------------- <br /> Z Private <br /> of living units:___.J___�____.Number of bedrooms_-__� <br /> Private <br /> Water Supply: Public System and name--:.---------- ---- ------- ------------------------------ -------- <br /> [�T <br /> Character of soil to a depth of 3 feet: Sand E] silt E] Clay ❑ Peat El Sandy Loam El Clay Loam ❑ <br /> ,Hardpan ]Adobe 0 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'-permitte.d' if public sewer is available within 200 feet,) <br /> r ... <br /> � .� <br /> . " Foundation De- <br /> th___-__-."------------ -Liquid <br /> PACKAGE TREATMENT, SEPTIC TANK Size --------------------------- <br /> Capacity <br /> ------------ - <br /> Ca acitY Material ` ----------------'-No. Compartments--=---- ------------- ------------ <br /> ------ ----- Type' - `"-- <br /> ---- ---- ------Foundation------- ------------------Prop. Line--- ------------------- -- <br /> s .Distance.to nearest: Well ----- ___- ----- <br /> ofeach line._- ------.Total Length --- -------------- ---------------- <br /> LEACHING LINE No. of Lines = .Length_ <br /> i �D' Box---------..Type Filter Material;_------------------Depth Filter Material----------------------------------------------------------------- <br /> F [ <br /> Distance.to nearest: Well---------------- ------.Foundation-----------------=-- <br /> Property Line_- ------------------------- <br /> SEEPAGE PIT E l Depth----------:'=----Diameter---------ms s--Number---------------------- <br /> Rock Filled Yes ❑ No E]E Wafer Table Depth'* ------------ ----- -------.Rock Size_.------------------------------------------ -- <br /> 'Distance to nearest: Well-1---------------------------------------- Foundation-__ � - .Prop. Line <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------- -----------------Date---------------:---------------------"--------- <br /> ---------- <br /> 1 <br /> y <br /> Septic Tank (Specify.:Requirements)-------- ------ -- ------- --- --------------- ----- = -------------- ------------ --------- -------------- <br /> Disposal Field [Specify•R -- .�. --- --------------------------------- <br /> i equirements)-- --- ------------ ----- ----- ------"------ ----------------- - <br /> ftt --------------------------------------- -- --------------- <br /> ------------- <br /> r <br /> --------------------------------- <br /> i ------------------------------------ -- ---------- -- -- --------------------------------- <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 Sari Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: . <br /> I "' sued, I shall not employ any person in such manner as <br /> ss is <br /> to become subject to Wo man's gormpensatio4n. laws of California." <br /> r -- - --- -------------------Owner ' <br /> Signed----------------------------- - - ------=- -- - - .- --- <br /> rl --------------- ------------------------- <br /> BY-;- - , <br /> -other than owner) <br /> FOR DEPARTMENT USE ON Y a <br /> APPLICATION ACCEPTED BY-_---- -. - : - <br /> ----------------------- <br /> DATE:------ <br /> -- ----- -- <br /> OF LAND NUMBER-- ------------------------------- <br /> - -------- DATE ---------------------------------------------- <br /> DIVISIONADDITIONAL COMMENTS------------------------------------------------ -------------------------------------- ----------------------- ----------- <br /> - <br /> -------- --------------------- <br /> = <br /> ---- ----- <br /> ----- <br /> --------------------------------------------- <br /> --- ------- <br /> � Final Inspection b - -- -- <br /> - -- --- - - - ----------- ---------- -�-- <br /> PY-. <br /> -Date- -- - --- --- <br /> = <br /> EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV- 7/76 3M <br />