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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 77 6 <br /> ----------------------------------- <br /> ------------------- P Triplicate) <br /> Permit No........ <br /> 4 <br /> o n�" (Complete in Tri licate) <br /> Date Issued----- - � <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/ -` /, -------- ------------CENSUS TRACT---------- ----- ----- -------- <br />, �Owner's Name- --- Phone---------------- <br /> - - - -- -- -- -• ----�----------------------- ------------- ---{� --------------------- <br /> Address- <br /> ------------ <br /> --- - ------------- <br /> AddressI� City ��` � ZAP <br /> Contractor's Name__- . ---. --_-- --- ------------License --Phone---------------------------------- <br /> P �/ - - - <br /> Installation will serve: Residence L� Apartment House.[:] . Commercial ❑ Trailer Court ❑❑ <br /> Motel ❑ Other--- -------------------------------------- <br /> Number <br /> ------- -------------------------- <br /> Number of living units-------- ______Number of bedrooms-. --I-.-Garbage Grinder------------Lot Size------ �' <br /> ---- - -- ----------------- <br /> --- <br /> Water Supply: Public System and name----------------------------------------------------------------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 21" <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 ij public sewer is available within 200 feet,) <br /> i PACKAGE TREATMENT [ ) SEPTIC TANK [ <br /> Size ------Liquid Depth ___f�________ <br /> n <br /> f Capacity_ eG-------Type_ -__Materia- ---------No. Compartments-___ __________ ` <br /> Y. Distance to nearest: Well_:_--___� 'G' _-----------------. Foundation_-_-_ ' ______Prop. !ine___- <br /> ---------- <br /> LEACHING LINE [ No, of Lines--------- Length of each line.______ ________.Total Length.__, _____._ <br /> --- <br /> 'D' Box----/_----T e Filter Material------5- -----Depth Filter Material______--I- --.________________________ __ <br /> ---Type - -- <br /> Distancato nearest:Wel l--------� ✓P ----Foundation.___.e/-d -----------Property Line_____a � _-_ _ <br /> SEEPAG'V <br /> E'PIT [ Depth__ Diameter_-------A;�__Number---------t3------------------ Rock Filled Yes No <br /> Water Table Depth-------------- --------------------------Rock Size--- y*' --------------------- \ <br /> Distance to nearest: Well---------Ile,-_______________Foundation.__16' ____-Prop, Line.... _____--___. <br /> tREPAIR/ADDITION (Prev. Sanitation Permit#-------------_'--•-------------------------------•-_.Date----------------------------------------------) <br /> `Septic Tank (Specify Requirements)--------------------------------------------------------------------------------------------------------------- ---------------------------- -------- <br /> Disposal Field (Specify Requirements)---------------------- -==-------------------------- ------------------------------------------------------------------------- ---------------- ----. <br /> 4 <br /> _________________________________________________________________________z___-________________-________-_________________________-_-___-_-___-____________________________-__________________-_-__----____ <br />+ Y <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 /> 1 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 Compensation laws of California." <br /> Signed ---'--Owner <br /> --- --------------- <br /> ------------------------------ <br /> BY------- - - --------------------Title__ :.�lr _ _ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY ) <br /> APPLICATION ACCEPTED BY----- .- " -- -- -------------------------------------------------------- DATE. Ir P111 ---------- <br /> DIVISION OF LAND NUMBER---------------------- -------- ------------------------------------------------------------------- --- DATE------------ ----------------------- <br /> ADDITIONALCOMMENTS-----------------------------------------------------------------------------------=---------------------------------------------- ----- ----------------------------- <br /> -------------------------------------- ------- ------------ -----------------------------------' ---------------------------------------------- -------- ---------------------------------- <br /> - - ------------------------------------------------- --------- -------------------------------------------------------------------------------------------------------------------------- <br /> - - ---------------- <br /> -- --------- . <br /> -- -- <br /> Final Inspection bY:---- --------- L�f' -- ---------------------------------------------------------- Date. ' -- ---------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ra,s 21677 Rev, 7176 3M <br />