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FOR OFFICE USE: * FOR OFFICE USE: <br /> ........... :... <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- . <br /> t {Complete in Triplicate} Permit No........`....�..�. j <br /> Date.lssued..�, ----- � � <br /> .............. This Permit Expires d <br /> 1 Year From Date Issue1 a <br /> Application is hereby de t e San Joaquin Local Health District for a perm:it,t>?construct and install the work here' described. <br /> This apple I� a e in c ounty Ordinance No. 549.a d existing Rules and R ul tions: <br /> JOB ADDRESS/LOCATIr NSU T T....----••--------_ ......... ! <br /> .. ... ... _-....-. .. r 4 <br /> i <br /> Owner's Name............. .. ....- :- ---... ......... .........................................Phone:..... ................ ----....... <br /> -- .......-- -- <br /> Address <br /> Zip z <br /> Contractor's Name - License #,�-87� .....Phone.--.. 1 r <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court-E] <br /> M tel .❑.: Other__.-.,. :.:------------------------ <br /> Number of living units:...... .......Number of bedrooms-.L Ga bage Grinder------------Lot Size..: .)........... . ...............:------- ---__ .. . i <br /> Wdter Supply: Public System and name................ - .............-...........-.-.-.--------------Private <br /> ffq <br /> Character of soil to a depth feet: ❑ Sii❑ ny ❑ Peat <br /> ❑ Sand <br /> yLoam Clay Loam <br /> , <br /> Had anF] Adobe El Material ___. .....If Yes;tYPe---, .. ' [ <br /> ` <br /> i <br /> )Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must'be placed on reverse side.) ) <br /> septicNEW seepage p p p se within 200 feet,) <br /> PACKAGE TAREATMENT [[!}o SEPTICtTn NKr see a e rt permitted if public sewer 1s available'- . <br /> [ j Size .. -.. .-L .1 Liquid Depth. . <br /> Capacity -LI. Type. .Material_ <br /> :�. p <br /> No. Com Compartments <br /> LINE Distance to nearest: Well_... .. e— ---..__._. .....V.-Fou cattiio.�n.. .. . ......... ...Prop. Line__...-.._......_...-------j i <br />{ [ ] No. of Lines .._... .... Length of aKich line . -- -d..............Total L1ngth .. . ._ �.-.-- .D' B T pe Filter Material..... ..Depth Filter Material._ Jr..............._......-._................_._--� <br /> y. 1 <br /> 4- Distance to nearest: Well-------------------- -------Foundation------------ Property Line... _..._......-----A <br />..SEEPAGE PIT Number.._.__ Rock Filled Ye No <br /> [ 4Depth. ._:...Diameter.. �?..... _ ❑ <br /> `Water Table Depth------------------------------ - ---------------Rock Size..'... ------------------------ <br /> Distance to nearest: Well------------------------------------........Foundation.--------------._.........Prop, Line----- -.---------- -------. I <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ---------------Date.......•-........--------. -.-------........._-) <br /> Septic Tank (Specify Requirements)--- - ------............................ .....-----------'-------- <br /> tS <br /> --- ... <br /> -------------....................._ <br /> ADisposal Field (Specify Requirements)..............:..• K- i <br /> -------................------............ <br /> ------- <br /> --------••- ----------------------- .................... ...........------------- ----------- ------ ----------------.... .......................... . ..... ---------------------- ........... <br /> --------------- -- ------------ ------------------------------ .................. --------------------------------- ------------ .. ------ •---.................. <br /> (Draw existing and required addition on reverse side) i <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 C nsation laws of Calif rnia." <br /> Signed � - - --•.----.-- <br /> �_ .. ....--'. ...:......... .... .... . .......Owner <br /> -. <br /> By............. C/- ---- ---------------------_ <br /> (If other t an owner) <br /> FOR D.JEE A TME USE ONLY <br /> APPLICATION ACCEPTED BY_---- -- - �------- ----- - --- --•-. -.-.......DATE ... Z .�3 ..�..._......-----........ <br /> DIVISION OF LAND NUMBER. DATE --- . ..... -- .. <br /> ADDITIONAL COMMENTS......... ......................... ...... ....... <br /> .......................... .... ............... <br /> --•-------•-----------•- <br /> Date....'- -- 1. - <br /> Final <br /> Inspection by:...._ - F&S <br /> - ... .. <br /> 1 --------------------- ---- ------------------ ------------ a �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 21677 REV. 7/76. 3M <br /> 1 <br />