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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------- ------------- <br /> (Complete in Triplicate) Permit No...................7_ <br /> 'f <br /> Date Issued4.-J_,?`�� <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 ane ulatiJgns_ <br /> _ ' s A 4 <br /> F 7 -� �- <br /> JOB ADDRESS/LOCATION.----�---------�-------- - --------- -��-----..,,� ---------�•-- :._..CE US TRACT-:==--'_-------------------- <br /> Owner's Name_ uss� - _ ------' " <br /> y - Phone <br /> Address-------- -- . ,1". u f --------------------- --------city -----Zi <br /> Contractor's Name ;ti'"- ,c-��± -�� fs- __.-License #--- ZSPhone- - <br /> Installation will serve: Residence LApartment House-.E] Commercial,T] Trailer Court <br /> rN <br /> --Motel-R-Other- <br /> Nu'mber of living units:- I_____.-_-Number df.bedrooms-�_--Garbage Grinder._.---_--..Lot Size------------- ---`--._.---:-.--__:_...___.__.,..___.___..__, <br /> Water Supply: Public System and name------ \ )4� -------------------------------------------- Private <br /> • , <br /> Character of soil to a depth of 3 feet; ' Sand'0 Silt ❑ Clay ❑ Peat ❑ Sandy Loam [] Clay Loam ❑ <br /> Hardpan Adobe-( F y Fill Material._.-.---__-_If yes, type----------------__.----_______- 1 <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 D"epth------------------------- i <br /> Capacity Type------------ Material = No. Compartments <br /> Distance to nearest: Well________________----___-----_.:_--------------Foundation.----_.__._---------------Prop. Line ---- <br /> LEACHING 'LINE [ ] No, of Lines--------,------..--------------Length of each line---------_---------------------Total Length._-.---_-_--.------------------------------ <br /> D' Box-.:.........Type Filter Material--------------------Depth Filter Material--------------------- ------------------------------------ <br /> Distance, <br /> -------------------.--- ----.-vDistance,to nearest: Well----------------------------Foundation----------------------------.Property. Line----------------------------------- <br /> SEEPAGE PIT [ ] Depth-----------=----Diameter---------- .--------.Number--------------------------------- Rock"Filled Yes'❑ No ❑ <br /> Water Table: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 (Specify Requirements) �i �h�� 'o � ° - - --'------------------------------ ------ <br /> ------------------------------------ -- ----- ----- ----------------------------------- <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»San Joaquin Local Health District, Home owner or licensed agents 1 <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 �I <br /> to become .subject to Workman's .Compensation laws of California." <br /> r <br /> Signed- ----:------------------ - ----------=-- ---- <br /> i •- ' J Title ____ �-C� <br /> BY = - vv � - <br /> r n 1A <br /> (If other than owner) `� 1 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -- - --- ------------ ....... ------------------------------------ -DATE..------=-- --------- ---------------------=--- <br /> DIVISION OF LAND NUMBER.---- ----- ------ -DATE---------------------------------------------- <br /> ADDITIONAL <br /> ----------- ---------------- <br /> ADDITIONALCOMMENTS---------- ---- --------- --------- ---------- ------------------------------------------------------------------------ - --- ----- ------ - -------- - --------- ---- <br /> ---------------------------------------- --------------------------------:­----------------------------------------------- <br /> ----------------------------------------=---------------------------------=-------------=---------------------------------- -------------------------------------- ------------------------------------ ) <br /> --------------------------------------------------------------------- ------------------------------------------- ------ ----- -------------------------------------------------------------- -------- <br /> ---------------------------------------- - - ----------- - <br /> p Y J <br /> ------ ----------------------------------------------------- ------ - <br /> Final-Inspection b G <br /> Date <br /> EH 13 24 -- JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> .I <br />