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FOR OFFICE USE: / FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> x <br /> l Permit No,2$=-1v7_ <br /> i (Complete in Triplicate) <br /> Date Issued. -� ' <br /> .••...................._....-... This Permit Expires 1 Year From Date Issued <br /> i '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 Or inance No 549 and 971sting Rules and Regulations,` <br /> im <br /> JOB ADDRESS/LOCATION....... ..�.P..V!` ..... -- --- ---------- -------- ........... CENSUS`kTRACT................. ........ _._. <br />' Owner's Name._.. `...-. ............. --- Phone..--.--------------- ---- ---_------ <br /> Address---------- <br /> --_------Address--------- ------.Ci .....zi <br /> Contractor's Name-..-... ... License # -Q - Phone. <br /> Installation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> ) Mo el ❑ Other..... ............. .. <br /> Number of living units:..................Number of bedrooms.....__.:... r age Grinder......... _Lot Size............... . .. . .....---------------------------._ .. <br /> Water Supply: Public System and name-- - ----- / .................... --- --------- -- ....Private ❑ <br /> Character of soil to a depth of 3 feet: i Sand ❑ Silt E]L Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ -t Adobe ❑ Fill Material . If yes, type--- .....--._........... <br /> i (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 /> I PACKAGE TREATMENT j ) SEPTIC TANK [ ) Size.....-- ...- Liquid Depth..........................S <br /> --- --------------------------- <br /> Capacity-...... ..- .: Ty.pe-----------------------Material-- -----• ­--------------No. Compartments-_--'-----_----_---- <br /> Distance to nearest: WeIL:--'_:: ..-_.....:....:........ . ::. Foundation-........- . ..-... ._....Prop. Line...............-......_.-- <br />' LEACHING LINE i_ h y s <br /> i f ) No. of Lines ----- --------- Length of each line". "�;----- ------- Total Length ... ----------------- <br /> D' Box. --. -...;Type Filter Material......... _.. Depth Filter Material_. .. .........-----------..--------------------------:--------- <br /> D.istanca to nearest: Well ...............:........ Foundation_--------.._....._------Property Line._._............_.-- <br /> SEEPAGE PIT [ ] Depth................Diameter------------- ----- Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth------------------..- -_-----.Rock Size.---------...........- _... -•-- <br /> Distance to nearest: Well................... .......................Foundation_-..---------------------Prop. Line------------.----.------- <br /> r <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------- ----------- -.-- -------- <br /> { r Date--------:.............�� . -------------- <br /> Septic <br /> ------------_Se tic Tank (Specify Requirements)...... �• ---- . . ..........I---------- - ) <br /> ------=--------------- --------- <br /> - <br /> Diposal Field (Specify Requirements)- --------- ----------------- <br /> -------------------------------------- .------ ............. ................ <br /> t - -------------•-------- - -----•------------... <br /> (Draw existing and required addition . <br /> on reverse side) <br /> I hereby certify that I have prepared this appiication 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: y <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 /> By-•--- G -. . ...---. .... Title - ------------------------ ----- ......... ........... <br /> {If other than owner ; <br /> t FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------\ DATE . .7.. . .......... ..... <br /> DIVISION OF LAND NUMBER.--. -- .......... - ' ..................... DATE <br /> ADDITIONAL COMMENTS..------------- ..... ..... ... <br /> l -------------- ------- --------------------------------------------------------------- -- ....... <br /> a ------------------------------------------ <br /> - --- .... <br /> Final-lnspedion -------------- --:Date... <br /> ' .. ............ .. <br /> " 's 74SAN JOAQUIN LOCAL HEALTH DISTRICT Fe 21677 REV. 7/76 3M <br />