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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT / <br /> ----------------- =------------------------- <br /> (Complete in Triplicate) Permit No..------------- ------ <br /> Date <br /> ---Date <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 and Regulations: <br /> JOB.ADDRESS/LOCATION.... -. -------- --- ------I ---- --- ------CENSUS TRACT- --------- - - --------------- <br /> Owner's Name------ - -- _ ---- ---- ------- - ----- ------ - ------ - ---------------Phone--- --------------------------------- <br /> Address-------------=----- d <br /> City_..__..._.. Zip----------------------------- <br /> Contractor's Name--------x�Lc ' -- G- �rr- --License # Phone-----------------------------= <br /> Installation will serve: Residence Apartment House.❑ Commercial ❑ -Trailer Court ❑ <br /> fMotel ❑ Other-------------------------- <br /> Number of living units:-------- -------Number'of.bedrooms-_--_3---Garbage Grinder-----------lot Size ---------- •=, f <br /> Water Supply: Public System and name = =__.---------------------- --------------- --Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt r] Clay E] Peat E] Sandy Loam EJ Clay Loam L]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 'septicytaiik7 or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------- ---------------------------------Liquid Depth --------------_----- <br /> Capacity- Type----------t------------Mate-Tial--------------------------No. Compartments------------- -----------=--------t <br /> Distance to nearest"Well "------=-----------------------------------Foundation--------------------------Prop. Line---------------------------- <br /> LEACHING LINE [ ] . . No..of Line's-------- -----------------Length of each line-----------------------------Total Length-`------------------------------------- <br /> D' Box---------.__Type Filter Material--------------------Depth Filter Material--------- <br /> ------------�--------------------------------------- . <br /> e i <br /> -Distance to nearest- Well________' .-____Foundation___ _______________________Property Line---------------------------------- <br /> _ <br /> SEEPAGE PIT [ ] Depth-----_s._----_.Diameter Number__________ ___________________ 1Rock Filled Yes ❑ No <br /> IWater Table Depth-- ----------------------------=------=---------- - ---Rock Size------------------------------------------------- <br /> -----.Foundation--------------------------Prop. Line.----------------------- <br /> Distance to nearest: Well_._.__________________._________ � .. <br /> 1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#..__--------------------------------------------------:Date----------------------------------------------f i <br /> Septic Tank (Specify Requirements)________________ __' --- ------------------------------------ <br /> Disposal Field(Specify Requirements)-------- <br /> t <br /> -----'-------------�--`�-------------art' =- --- - ----- - - ---------- ------ ----------------------- <br /> ---------------------------------------------------------------=----------------------------------------------------------------------- -----------------------------------_------------------_--------------- <br /> (Draw existing and required addition on reverse side) i <br /> hereby certify that'll 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 :Wanner as <br /> to become subject to Workman's Compensation. laws of California." <br /> Signed----------- - ---------------------- Own <br /> _ .. <br /> gY ` - �` Ti#le_✓ �� �`"__rf --------------- --- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED BY--- ! - "---DATE - - <br /> --------------- --- - <br /> DIVISION OF LAND NUMBER_____________________ - -----DATE-__.--------------- .- <br /> ADDITIONAL COMMENTS---------------------------------------- -------------------------------------------------------------------- ------I-------- --------- <br /> ---------------------- <br /> -------------------- --------- ----------------------------- --------- -------- --- ---- ------- ---------------------------------- - --- --- ------------------ -------------------------------------------------- --- <br /> _ ----------------------------------------------------------------------------- ------------------------ - ------------ --------------------------------------------------- -- <br /> ------------------------------------------- = ^-� ---�- <br /> Final InspectionbY: c` CJ -- - -- - -----------------------:---Date.----- -----�---.�-- ,— <br /> EH 13 24 SAN JOAQUI LOCAL HEALTH DISTRICT Fss seen Rfv. /�e 3M <br />