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FOR OFFICE USE FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------------- Permit No.,7� <br /> I (Complete in Triplicate) J--- - <br /> --------------------------------------------------------- <br />� Date lssuedfD.._1/9=-2r <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 o. 549 and existing Rules and Regulations: <br /> 1 <br /> JOB ADDRESS/LOCATION __ O � CENSUS TRACT"___________ ____ <br /> ------ -- ------ <br /> OwnerAddress p i one <br /> 's Name -------- -- --"------------------•--------------- --- - --- ----Ph -- -------------------- <br /> IX <br /> --- -------------- <br /> - /{ City t -- -----------Zip ------- ---------------" <br /> Contractor's Name- -._-- `- ----- [ -------License #---'fib'. . -_�G;__Phone-j <br /> k.. = ` `. -- <br /> Installation will serve: ' Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ f <br /> ;,. e• µ Motel ❑ Other--- - ---------- ------- ------ --= -------=- <br /> F Number of living units:._-_- ------.__Number..of,bedrooms---- -Garbage Grinder------------Lot Size...... ............_........ <br /> ___ <br /> l Water Supply: Public System R <br /> + � ,and narrie, � ' -- =-- ------------------ ..-.----.. : _ .- -�-�-- ... " .,. -�-- -r _- - --- Private 7F;r` 1 <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay gill' Peat E] _Sandy Loam ❑ Clay Loam ❑ <br /> } - - hardpan 0#Adobe E] Fill Moterial__-_. _ If <br /> [Plot plan, showing size of lot, location of system in relation to"wells, buildings, etc. must be placed on reverse side.] s <br /> NEW INSTALLATION- `;(Noseptic tank "or seepage pit permifteIif public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [-1-t-SEPTIC•TANK-[=], —^--Size------------------ ----------------------- t Liquid p <br /> - uid'Depth ------- <br /> Capacity:-----I------------ <br /> -Capacity:.----I-------"----=-TYPe----- --- - AAatarial- --------:---------------No. Compartments-- ------------------------------- <br /> � .aflistance'to nearest: Well .. Foundation Prop. Line _ <br /> 4 LEACHINGYLiNE; [ ] No...of Lines--------------------------------jTotal Length ' ---___ .__ r <br /> I - _ . ... Length.of each�]ine---- -- -- -- - - ------------------------ <br /> Q' Box-- --- --- Materia! ------ ---- p ---��- <br />[ - De th Filter Material <br /> r sr� -------- - <br /> Distance to nearest: WeIL______________st._________Foundation______________________..__.Property Line________`________ <br /> SEEPAGE PIT [ j Depth----- ----------Diameter---------------- ---Number_--..-__t__-_-------------------- Rock Filled Yes ❑ No E] <br /> _ , <br /> Water Table'Qepth- `----------- --------------------- -------I- --- Rock Size- ----------------- - ?K <br /> .ti Qisfance'.to.nearest Well-_ -------------------- Foundation---------------------- -Prop. Line---:----------------- <br />[ REPAIR/ADDITION (Prev. Sanitation"Pmit#_.----- r----------------Date.-_. -off- -3------- -------- <br /> tSeptic Tank (Specify Requirementsy.----'------------------------------------------------------------ ; =---= ----- -- - -- -- -- -----:-=---- ---- --------------------------- <br /> Disposal Field,(Specify Requirements],.,--.__ - ------------- - ---------------- <br /> ___._.,_,_---------------------------- _ ------._----____ _ -___-. __----------------- ---------------------------------------------------------------_---------------------------- <br /> ----- <br /> _ .. -_ <br /> _ - ---------------------------------------------------------------------------------------------- ------------------------------_--------------_ _ ------------------------•-----:-------- --- <br /> # w [Draw existin and requ ed additionw.on reverse.side] <br /> -1 <br /> here b"yrcertify that I have prepared ibis application -anil.that the°work will •be' done in accordance with Son Joaquin County <br /> Ordinances,: State Laws, and Rules and Regulations of the Son Joaquin Local Health District, Home owner or licensed agents <br /> i signature certifies the following: t <br /> "1 certify that in 1he'performa ce of the `work for'."which'this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation:lows_Of. California.:' .._ .. ... (_... .. - . ;.. -•, .. � <br /> i Signed-=------------ ------------------ _ ----- <br /> � <br /> -- ----- - ---- --- - --Owner <br /> e <br /> - ----------- ------ <br /> BY ` - Titl <br /> € (If other than'owner[ u <br /> _ .. <br /> FOR'DEPARTMENT'USE-ONLY <br /> APPLICATION ACCEPTED - ------------=------------------------ - DATE.'�G <br /> 1 DIVISION OF LAND NUMBER.------`---- =------------------ --=------- ----= -- -- DATE------------------- - <br /> ADDITIONAL COMMENTS ------------------------------------------------------------------- , <br /> -------------------------------------=------------- - - ----------------- ---------- --------------- ----=-------------------------=--------------- -------------------------=-- --- <br /> -' = - -------------- - <br /> ---- =------------------------ -- - ---'------"-------------------------------------------------------------------------------------------------------------------- - - -------- <br /> Final Inspection,b ---- <br /> EH <br /> 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FES 21677 REV. 7/76 3M <br />