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FOR OFFICE USE: FOR OFFICE USE: <br /> 1 APPLICATION FOR SANITATION PERMIT <br /> -------------------- --------------------- Permit No7 _-_a(,_.;_ <br /> (Complete in Triplicate) <br /> ------- Date , q <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 ounty rdinance No. 544 and existing Rules and Regulatyon§:, <br /> o <br /> JOB ADDRESS/LOCATI N_ .--...CENSUS TRACT..............' - - <br /> Owner's Name..._.. <br /> -- --------- - --- - - --------- -- -------- ------------.....Phone------ ------ <br /> Lt��Lnt �. zi P <br /> 4----�----9---a--- <br /> ------ <br /> ,Address. = .. city <br /> - ------�---- <br /> Contractors Name .-- ----------------------- ^'�--�.Licerse ---Phone----- ---------- --------- <br /> Installation will serve: Residence 1!f/ Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------------__....---.... ----------------- <br /> Number of living units:_.__"`.-_._..__Number of bedrooms...._.3----Garbage Grinder------------Lot Size------ ------------- ---------- <br /> Water Supply: Public System and name----------------------------------- --•--•- ------------------ ---•-"•----- ................ ----------------•-• --_.Private ElCharacter of soil to a depth of 3 feet: Sand EJSilt❑ Clay ElPeat Sandy Loam ❑ Clay Loam ❑ <br /> 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 septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ } SEPTIC TANK [ ] Size------------------------------------------- ----------:--.-liquid Depth----------------------- <br /> Capacity----- <br /> _.-.----..---.-..-.-.-Capacity----- --- -------Type............. Material ......No. Compartments-------------------------------- <br /> Distance to nearest: Well--------------------------------------_.-Foundation-------------------------_-Prop. Line--.--.-.---..-.------_..._ <br /> LEACHING LINE [ ] No. of Lines-----------------------------Length of each line-------------------------------- Length---------------------------------------- <br /> V Box............Type Filter Material--------------------Depth Filter Material--------------------------------------------------------------.. <br /> Distance,to nearest: Well----------------------------Foundation---------------------.------Property Line.-.--- ---------------------------. <br /> SEEPAGE PIT [ ] Depth----------------Diameter....----.-----------Number-------------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth---- ----------------------------------------------------Rock Size---------------------------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation-----------------------__.Prop. Line_----------------------.._ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.---.---- ------------------------------Date-__..--- ------------- -.--------- ) <br /> Septic Tank:(Specify Requirements)------ --------- ---- -- ------- ---------- ----- ----------------------------------------------------------- } <br /> Di osal Fleld (Specify Requirements).0 .__.d- < '-�j--- ---- ------- ----- --- <br /> -- -------- <br /> & ., = --•----------------------------------------- <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 <br /> signature certifies the following: <br /> "I certify that in the performance 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 laws of California." <br /> Signed-- - ---- - ------- ----------------- Owner <br /> z� s Title...Allwf�__21!'- ------------------- <br /> SY = --- ------ /!W - '.... <br /> [If other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.-.-" DATE _. ._. ------------------ <br /> DIVISION OF LAND NLIMBEl2.. <br /> -----------------------------------DATE.--- .-....._--- .-.-.... <br /> ADDITIONALCOMMENTS---------------- - -- ----------------------••-- •------------------------- - . ............ --------------------------.------------------------------­- ........ ....................... <br /> ------------------------------ ---- ---- ----------------- ---- --------- ---------------•----------. - <br /> -- ---------- --- ---- ---------------/-' ----------------- ------ ------------------------------.-... <br /> Final Inspection by..--.----ice �_�-- --- - Jf <br /> ---------------- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f/ F&5 21677 REV.7176 3M <br />