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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ......•.......... .. •. Permit No.�?--W1 <br /> (Complete in Triplicate) A <br /> Date issued-j�........ ..... <br /> ......................................................... 'This Permit Expires 1 Year From Date Issued <br /> 77. � <br /> Application is hereby made to.the San Joaquin Local Health District for d'permit to construct and install the work herein described. <br /> This application is made-in compliance with County Ordinance.No. 5J9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION. ---•7" .. ....... L---------.--...---..CENSUS TRACT -------•--- ---•--- <br /> Owner's Name'_.. . ........ .... ------- ._.._. Phone. :....------. ........... <br /> Address . . _.... Q �/- ° -� --- .. w_... - City - ....Zip <br /> -- - <br /> �.- <br /> ...License # �I �J Phone....---=•-------------------- ... <br /> Contractor's Name. - v' .._.6 . . .. <br /> Installation will serve: 'Residence ( Apart ent House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--------------------- ------------------------ <br /> Number of living units______ _________Number of bedrooms_.......Garbage Grinder------------Lot Size.__. ` ............. <br /> Water Supply: Public System and name........�:...� . :---•.............. .................... ........... ........ -----Cla Loam - --- --- --..Private <br />[ Character of soil to a depth of 3 feet. Sand El Silt E] Clay E] Peat E] Sandy Loa ❑ y <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:I`` (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) IF <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size..... . . _ . �- -�0-_-- --- --Liquid Depth._..................� <br /> • . Ca acit �_} d -___T e _ Material__. No. Compartments -- -----.---- <br /> r f„ p. Y O �� Yp -- - •- <br /> - <br /> .. ,..!. �Distance to nearest:�Well A�.�_���--...�------- --------------Foundation..�_.Q.. ....Prop. Line_--,� <br /> • . <br /> IF, <br /> LEACHING LINE [ } ],Nb. of Lines_,--.. } .......Length of each line,_ -.f7 ....Total Lerngth -/ LP <br /> --------- ----.------'D' Bo Filter Materia.=.1. 7 -Depth Filter_.Material_.. _ i....................., <br /> t <br /> =1--_Distance to nearest: Well........ _ ..........Foundation----------------_-__....Property Line----------.--- <br /> + SEEPAGE PIT [ ] Depth---X.J� ...Diameter--0,_17_.....--.Number....__-_- -------------- Rock Filled Ye SN <br /> No <br /> Water Table Depth------------------------_-- ---------- - •-----_----.Rock Size... . ------------- <br /> Distance to nearest: Well.-.-/-----i?-- -.-- --- ---..-Foundation------------------- - ---Prop. Line.. ........ .------. <br /> } --------------------:Date_..--- _- -----) <br /> REPAIR/ADDITION (Prev. Sanitation Permit#..............:.."-_-.-.- ------- <br /> ------ <br /> Septic Tank {specify Requirementsl-- -------- - ----------------------- = _...... <br /> Disposal Field (Specify Requirements),_............. <br /> - <br /> ---------------------------- <br /> --- ------- -------- <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 /> i signature certifies the following: F <br /> f <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 /> iSigned-- --------- -- - --------------------------Owner <br /> By------ .... <br /> Title........... ------------• ............. ......... <br /> ]!f other than owner) <br /> R _ PARTME T <br /> APPLICATION ACCEPTED BY------.-- . - ------ ------ •---- ! - ...�.... ... -... --.- <br /> DATE <br /> DIVISION OF LAND NUMBER--- -------- -- ------....--- DATE.. ...... ------ _--- . . <br /> ADDITIONAL COMMENTS------- --- ------- <br /> -•---- ---•---------- ------ ----------------------------- --------..._... <br /> -------------------- - --•---•------------- ------------•.............................. <br /> .-...... <br /> ----------------•• -- --- <br /> ---•---- <br /> 11 <br /> `Final Inspection by - -- ---------------------------------- -----------------------------------•---------------- Date.------- -----_- - ---------- <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7176 3M <br />