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FOR OFFICE USE: <br /> } FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> /f_� <br /> --------- (Complete in Triplicate) Permit No.7__�_..__ _______ <br /> ----------- ---------------------------- --- ----------- 4:"41 Q <br /> ] Date Issued_ :1,5`:7p <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,Ord:inance-No. 549 and existing Rules and Regulations: <br /> i <br /> e-, _ .,.� W sem,- �. - .T . _._. _ - . _.., _ . _. _ <br /> i <br /> JOB ADDRESS/LOCATIO -- �------------ - -------------------- -- -------------------------CENSUS TRACT----------------- ------- <br /> Owner's Name.......... <br /> A hone <br /> -- ----------------- ..---.. <br /> ct, <br /> Address = P <br /> .. - --- --- City Zi Name_____.__ <br /> -------License # .--------Phone_---------- --------------------- <br /> Contractor's Installation will serve: Residence n Apartment House EJ Commercial ❑ Trailer Court.[:] , <br /> } -i. Motel I] Other-------------------------=-- `------------- <br /> Number <br /> -----------Number of living units:_____-------- <br /> ---Number of bedrooms:.__' __Garbdge Grinder------------Lot Size------____________- ,-- <br /> Water Supply: Public System and name-- : -------- i-----------=- --------•-•---------- ----------------------------------------------------------------------Private <br /> '4 � <br /> Character of soil to a depth of 3 feet: Sand. �. Silt❑. .Clay ❑ r Peat❑ Sandy:Loam I/ Clay Loam ❑ <br /> lardpan ❑ Adobe❑ Fi Material_-----------If yes, type----.__________________________ y <br /> {Plot plan, showing size of lot, location of sysfemin rrelation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: ,(No,septic tank or seepage pit permitted if public sewer is avpilable'within 200 feet,) <br /> i <br /> PACKAGE TREATMENT ' a ;SEPTIC TANK . <br /> [rot. 3. [�] � � � Size-------------��-- ------------.•....._•--•------------------Liquid Depth-.------------------- <br /> r Capacity-`--------------------Type --------- -----------Material-_3------------- -:-No. Compartments-----------------------.----------- <br /> 4 <br /> Distancejto.nearest:_Well--------_..:_, --- --.---Fou ndation__=._�---------=---------Prop. Line-----=--------.-------.---.- <br /> j <br /> LEACHING LINE_ [_] No. of Lines- --------------- if of each Line---.--------.--_'-_-.--.-----------Total Length ------------------- --- <br /> - .- ,- - --- -- <br /> i 'D' Box {----;__Type Filter Material___ p FiIfer`Material_. _-----------------_____ _ <br /> Distance.to near_est.-W6ll,--=_''-•'--.Foundation---:------'------------------Property Line--------------------------------f <br /> SEEPAGE PIT [ ] Depth---------------_Diameter---------------------Number...:------y____________________ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth = = -------'--Rock Size------------------------------------------------ <br /> Distance to nearest: Well-- -----"----------------------------------Foundation------------------------------Prop. Line---------------------------- <br /> RE0AlR/ADDITION (Prev. Sanitation Permit#-_' ____________ -------- - Date__:___ - ) <br /> Septic Tank (Specify Requirements)----------- --- - = =' "-------------- ----------= := ` <br /> 8 Disposal Field (Specify,Requirements) -- --- `" ' - �,-------- -- <br /> �� -- --- . --- - ---------- = <br /> - <br /> ----------------------- _-_------ ------- <br /> Draw existing and required addition ---- -------:- -_�--._._----.----- <br /> --* - L_ T <br /> . ( g q tion'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 1 <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 /> "II certify that in the performance'of' the work for which this permit is issued, 1'shall=not-employ any:person in 'Such manner as <br /> to become subject to Workmans...Compensation laws of California." <br /> Signed------------------- --------=---- = - --------- ------Owner i <br /> J <br /> BY-=------- ----------=------ - ----- Title. - t ------=---- -- -------- - -------- -- <br /> -- .. <br /> • (If other than owner} <br /> 'FOR-DEPARTMENT" USE ONLY' I i <br /> APPLICATION ACCEPTED BY '----------�- === = == -------- ` - DATE. 3- <br /> DIVISION OF LAND NUMBER.---..---- ----------=--- ---- --------------------- - ----- -------=---DATE--------------------------------------------- <br /> ADDITIONAL <br /> ------------------- ---ADDITIONAL COMMENTS.--- = <br /> I <br /> ----=----- - ------------------------------------------------------------------------_L ------ ....... <br /> - ------------------------ --------- ------------------------------------- -- -------------------------------------------------------------- ------ <br /> -------- ---------------------------- <br /> Final inspection by --_'__------- - i �'. Date. <br /> OAQUIN <br /> EH 13 24 SAN JLOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 sen <br />