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FOR OFFICE USE: ✓ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------------- <br /> (Complete in Triplicate) �� Permit No,Z�'-'_- _"y <br /> --------------------------------------------------------- JJ <br /> Date Issued--- <br /> Application <br /> 7� <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-- ►_ ____. 1;Cta1 v- ------- ---- ---- ---- ----------CENSUS TRACT-,j;- � <br /> Owner's Name.-..-- - - - - -------- <br /> Address---- <br /> ---Address---- • -- --- ----------------- ---City---- -c Zip------------------------------ <br /> Contractor's Name______ - _,,.2 �- <br /> -------------------------License #- -S� L`_______-Phone_ '� ---------- <br /> Installation will serve: Residence fp-'Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------------------------- <br /> Number of living units:------/------Number ofjar,oms____2i___Garbage Grinder.-- _.__Lot 5ize_'_I' _�__->rle o. <br /> ------ -- ------------- - <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 /> - HardpaQO� Adobe-v 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 [ ] Size------------------------------------------- ---------------Liquid Depth.-------------------------- W <br /> Capacity---------` ; ----Type- - ---- ---- ---------Material--------------------------No. Compartments ---------------------------------- � <br /> Distance to nearest: Well-------------------------------------------Foundation------------:_------------Prop. Line_.------------------------_. <br /> LEACHING LINE [ j Na. of L•ines_---------------------------Length of each line-----------------------------_Total Length --------------------------------------- 0 <br /> 'D' Box---------.--Type Filter Material--------------------Depth Filter Material-------------------.------------------------------ 5 <br /> A. a'., 4 <br /> ,< Dist&nce 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 /> SepticTank (Specify Requirements) ------------------------ --------------------------------- ------------- --------- ------------- ---- ------------------------------------------------- <br /> Disposal Field IS Re rements) '�r / ^ / C. / c == � d. ----------------------- <br /> ----------------- ------ --------- - <br /> --------_ -- <br /> -------- ---- <br /> (Draw existing and required addition on reverse side) <br /> 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 performnce of the work for which this permit is issued, I shall not employ any person in such manner as <br /> a <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-----.--1--- -- ------- Owner <br /> BY------------- 4=� ------Title--- t - - <br /> - -------------------------------- <br /> ----------- <br /> (If other than owner) <br /> FO EPART ENT USE O14L'Y4 <br /> APPLICATION ACCEPTED BY----- -rte ` DATE.--.-- <br /> ---------------- <br /> DIVISION OF LAND NUMBER.--.--- - Y ! ---------- DATE.----_-- ---- --------------------------------- <br /> = -------------------- ,- <br /> --------- ---------------ADDITIONAL COMMENTS---------- ------ <br /> --------------------------------- <br /> ---- <br /> ------------------------ ------------- ------------------------------------- =------------------------------------------------------------- --------------------------------------------------------------------- <br /> ------------------------------------- - ------------- ----------------------------------------- ------------- <br /> --------- - <br /> FinalInspection by -� ------------------------------------ -------------------------------------------------Date---- -------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />