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FOR 0FFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT9-. i <br /> ....--- --- - -•�--- -•- Permit No.�. ' <br /> (Complete in Triplicate) r� .-"....... <br /> Date Issued_L.`a.6779 <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, 544 and existing Rules and Regulations: <br /> JOB ADDRESSAOC <br /> ...................... y <br /> - - <br /> .. ..... ........................................... ..........CENSUS TRACT..----...------ . <br /> Owner's Name... <br /> ..... ... -- -- -- - Phone <br /> Address............... ......... City-•-- ----- -- ...--- ........Zip--- f <br /> -- ----- --- ------------ ------ ------ � ,moi' �r <br /> 11 <br /> Contractor's Name _Aicense V-- (7f.....Phone...7`1�.�5�_ .... .1... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_..... -------------- <br /> Number of living units:..........---...Number of bedrooms......--....Garbage Grinder--------....Lot Size.------ . ..... ...._-............_- -- -- <br /> Water Supply: Public System and name....... • .... _ .-------- --------- .................................... -------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt F] Clay ❑ Peat ❑ Sandy Loam ❑ 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 public sewer is available within 200 feet,j <br /> PACKAGE TREATMENT ( ] - SEPTIC TANK [ ] Size - -------------------------------••------------ ----Liquid Depth..............------.----.-- <br /> Capacity.- ...... -----Type................ ......Mate.vial.-------------------------No. Compartments--------- ........................ <br /> Distance to nearest:,Well. .............................--.......Foundation--------- .. .............Prop. Line..----------.----..--------- <br /> . <br /> LEACHING LINE ( ] No. of Lines -.--.---------------------Length of each line --- ---- Total Length .. ............................... <br /> -.--- k <br /> 'D' Box......... ..Type Filter Material-- Depth Filter Material.. ................ ............................................ <br /> Distance to nearest: Well--------------- .............Foundation............................Property Line-------------- ----.------. <br /> SEEPAGE PIT ( ] Depth._............Diameter.....................Number---------------------------------- Rock Filled Yes ❑ No ❑ <br /> I <br /> Water Table Depth........................... ... ......... ...............Rock Size..-------- ...------ -- ------------------- <br /> Distance to nearest: Well_..........................._..........Foundation- Prop. Line --------.-----.--..-------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#..........--------:................. ...............Date......................------............. <br /> -..-_-] <br /> Septic Tank (Specify Requirements)----......... ------------ ---- ------- --- --- ------ <br /> Disposal Field (Specify Requirements). ...---.-- --------------------------------------- <br /> ...... = ------------- -- --------- <br /> r <br /> ---------------- - ------- ------------- <br /> ....---------- ----................... <br /> IDrow 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 Son Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "1 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 subjett to Workman's Compensation laws of California." <br /> g <br /> 5i ned. -- -- ------------ -------- -• - Owner <br /> BY ........... Title.... . <br /> �_ ;_! <br /> (If other than o eri <br /> TPR D ARTME T SE ONLY <br /> APPLICATION ACCEPTED BY -----..DATE - .... .... <br /> DIVISION OF LAND NUMBER............... .. �I^'- . . DATE....... <br /> ADDITIONAL COMMENTS...--------- --_---- ----- ----- -- -- <br /> --------------- ---...................................................... ............. ---......... -....... <br /> ...... <br /> .................. ...-........... ------------------ ............ --------------------------------------­. ......... -•----.......-. ---------- ..------- <br /> --------------------- ---------- -- - �[���, --- - --- ------ `s--- ----- - -- <br /> Final Inspecfian by:................ �--�' ..----- --------- ....---- . -----------_-------------Date....._�`.�.�.--7-.�- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. fT{6 M <br />