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FOR OFFICE USE: , f FOR OFFICE USE-. <br /> APPLICATION FOR SANITATION PERMIT � <br /> ....................... . Permit <br /> ................ <br /> (Complete in Triplicate} <br /> --------------- ....__.......------- --. / ' � <br /> Date Issued. ..----.....- <br /> 7 <br /> .......................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby mode 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 /> J - <br /> JOB ADDRESS/LOCATION .. .. 0./.. !--"----- - ....... ---- - .....CENSUS TRACT.. <br /> Owner's L!- Nce .m - -. .. ................. Phone. - <br /> /� <br /> Address..- - Lyt:/--------- . City ---- <br /> .............. ---zip---=.............._.......-- <br /> Contractor's Name.... ... :. License #- - 1 �.."...Phone .. �a . <br /> Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ <br />�= ❑ p ❑ <br /> Motel ❑ Other------- --------- --------------------------- <br /> Number <br /> --- --------•-------..----Number of living units:..../---------Number of bedrooms..--!' -Garbage Grinder-------""-..Lot Size----1Q"--- <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 Laam {� <br /> Hardpan F1 Adobe E] Fill Material.. ... --- If yes, type-.---"------------------- ---- ✓� <br /> F [Plot plan, showing size of lot, locationtaf system in relation to wells, buildings, etc. must be placed on reverse side.[ ^ ` <br /> i NEW INSTALLATION: (Na septic tank or seepage pit permitted if public sewer is available within 200 feet,) t" <br /> i <br /> PACKAGE TREATMENT SEPTIC TANK I ] "'' Size ...! X =- --FJ -.---------Liquid Depth.-— - --.- - - <br /> n <br /> --- - -- <br /> Capacity/("9V..... �j -- No. Compartments -"- -- <br /> Distance to nearest: Well..-_ --tv------ --- - -- ---------Foundation...""...- Prop. Line.--------- ,,._. <br /> t <br /> LEACHING LINE [ ] No. of Lines ._ a. J .-- :.- --:. Length-of_each line------ -0-------------Total Length !.-goZ-�.......:.........-------- <br /> ro <br /> 'D' Box..../......Type Filter Material_-� .j . . Depth Filter Material_--,.$.-.-" .......Q <br /> � 1 <br /> Distanc5to n=arest:.Well--- -- -- -----------Foundation--- <br /> Property Line ------------ ----• <br /> SEEPAGE PIT [ ] De th.-. �?.1.Diameter-.--- �_Number (�-"........_ .- <br /> Rock Filled Yes ❑ No <br /> P V <br /> rWater Table Depth --, ---------- --.... ..----- .........Rock Size--- 1 - <br /> Distance to nearest:Well.__ _:Z---- ---- .. <br /> ----------- - -------Foundation. -( p.........- Prop. Line.------.---------- ---.... <br /> REPAIR/ADDITION (Prev, Sanitation Permit#-;--------------------------- "--- bate--------:.......----- ------.--.--- ----------1 <br /> Septic Tank (Specify Requirements)---_ -.....--_.." " i- "" .._ """....... <br /> i . <br /> l Disposal Field (Specify Requirements)...--............... ..... - - <br /> ..............."".."......-...--..--._"""""""--...-... .-.. ... ...""-..-.- -• .3-'-----"....---.....--------------------------...--_• --.......... .._..-. .-.-._-.- .--.___... ..-...___.- - <br /> t (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 San 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 Workman's Compensation laws of California." <br /> Signed.-- --------- - ----Owner <br /> - - - , Title ................. .................... .. ...-.------------ _........ <br /> I o er thanowner <br /> FOR EPART ENT USE ON Y <br /> APPLICATION ACCEPTED BY...------- - -lL�-------- --- - ---•- - ...---- - -- <br /> pz . cx.� ........ .DATE - 1. ... ------ <br /> DIVISION OF LAND NUMBER ----- ------ :... DATE._.-. - .... <br /> ADDITIONAL COMMENTS....- <br /> _ - <br /> ` ----•-------- ----- - ----- -- ,1e��.� � �.._��:. f�� �� .....__. <br /> ---------•----------- <br /> ..--------•------------------------- ++. - __-�_ .------"------.•----------'-_--- -...--- _•.J" <br /> ..--- .... -- ." <br /> Final Inspection b <br /> y:.-- .. G L -�� <br /> _".. ...Date .. - <br /> Eli 13 24 SSA�t'JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7l76 3M <br />