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els FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------------------- <br /> (Complete in Triplicate) Permit <br /> --------------------------------------------------------- c <br /> -----------------------_......_--------------_----------- This Permit Expires 1 Year From Date Issued date <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/LOCAZL <br /> ' . - ----------------- ----CENSUS TRACT------_--- <br /> ----- -------------- ----- -- -------------- --- ---Phone-------------------------- <br /> ----- <br /> Owner's Name - - <br /> city_- Zip Address------------- <br /> Contractor's Name--------- <br /> icense # 7Phone_.. <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ <br /> Motel ❑ Other___--z:- - - <br /> Number <br /> z:- _ .Number of living units:- Number of bedrooms----- _._Garbage Grinder------------Lot Size---- <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 Pa-1- <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 ifpublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ l SEPTIC TANK Size_ `r'� <br /> [ Liquid Depth. <br /> Capacity.,/_____,Zn�------Type_ __ ' - _. rial * _------No. Compartments-- --------------------------- <br /> MateDistance to nearest: Well__.------- �_C---------------------------Foundation----- -C---- ------.Prop. Line------. -------------__-- <br /> LEACHING LINE [ No. of Lines-----._-_�---------------Length of each line __---- ,0___ _______._Total Length. ------------------ <br /> 'D' <br /> _____ _____-_--__'D' Box_._Z-----Type Filter Material------ Filter Material________ ---- ---------------------------------- <br /> Distance to <br /> _________________________________Distance•to nearest: Well------- % ---------.Foundation-------la.............Property Line------- <br /> SIS T Depth------- Iielrx�#er. --- - - --Number------------ ---_------ --- Rock Filled YesNo.-❑ <br /> Water Table Depth--------------IL-10 ---------------------------Rock Size----- ----------- 3 <br /> I <br /> Distance to nearest: Well-------IA�-. ----------------------------Foundation-----.1 ............Prop, Line_____ '---`._. <br /> ------------ --- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__-._- -------------------------------Date-------------- -----------------------____----) <br /> Septic Tank (Specify Requirements)------------------- ---------------------------------------------------------------- - ---------------------------------- <br /> DisposalField (Specify Requirements)---------------------- --------------------------------------------------------------------------------------------------------------- -`--- <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, 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 /> l 'BY---------------------------------------- -- -------- Title <br /> (If other than owner) ! <br /> FOR4PPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------C-- -- - ---DATE--- <br /> DIVISION OF LAND NUMBER ------------- ----- ------------------- --------------------- ---------- - DATE.-.---------------- --------- ------------------ <br /> ADDITIONALCOMMENTS -- --------------------- ---------------------------- ----- -- - -- ------------ --- --------------------------------------------------- <br /> ------ -------------------------------------------------------------- ---------------------------------------------- -------------------------------------------------------------------------------------- <br /> ----------------------- ------------------------- -------- -------- -------------­--------------------------------------------------------------------------------------- <br /> -------------------------------------------- <br /> - ------------------------ <br /> Final Inspection by:.----------C� = r ----------- ----------------------------------------------------------------Date------ ----- <br /> EH 13 24 5AN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7176 3M <br />