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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------------ <br /> (Camplete in Triplicate) Permit <br /> Date Issued Issued.,571.___-7. <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 /> P-- _ <br /> % ----------. --.-CENSUS TRACT-------------------------------- <br /> JOB ADDRESS/LOION--- a <br /> Owner's Name.• . <br /> ----- ----- - �'----- --- Phone-------------------- <br /> Address 1+��� �1----1v----'�P `�------- ---------------- ---- ------- ---- CitY - ZiP �� ^z r� <br /> Contractor's Name -------&Z.........License #--32 _____Phone_________________ <br /> Installation will serve: Residence [e Apartment House.E] Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------------------------------- <br /> Number of living units:-------- ___Number of bedrooms__-;---Garbage Grinder------------ Size____________________I-__ _____ -------------.--------.- <br /> Water Supply: Public System and name-------------------------------------------------_--- _-------- _.---------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 2!( Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material............If yes, type______________________________ K <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be-placed-on reverse side.) r" <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available wifthin 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [Y] Size_._ �.��.___11 _1-----------------------____________Liquid Depth....... _.___._.__._______ <br /> _MateriaLJXr_____No. Compartments <br /> Capacity.j��---------TYPe-/� -- - - p z" --------------- <br /> / Distance to nearest: Well._ ._____.__ .Q�1­__;�-___.___Foundation_____._:_ Prop. Line___ _____________ <br /> LEACHING LINE [v] No. of Lines------.-__-_�_____________Length:of each line,---------- ','__.Total Length.___._1;:;>-,n_�_.------------ <br /> 'D' Box.-_./-------Type Filter Material.---' ' --.Depth Filter Material---------/�------------------------------------------------- <br /> Distance to nearest: Well_____' __ ------Foundation-----------L_Q._ .__Property Line_______v__K_______________ <br /> IT [ Depth----1;�........ ir_--2_ &__:Number----------�----------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth------------------$A__ -------------------------Rock Size----��-.� - ------------------------- <br /> Foundation._---__f�_ ____ Prop. Line.____.--_ <br /> Distance to nearest: WeIL__._.__..j- __• _ _----------_ ___ S <br /> REPAIR/ADDITION {Prev. Sanitation-Permit#--------------------------------------------------\Date.--_------------------------------------------ <br /> ) <br /> SepticTank (Specify Requirements)-------------------------------------------------- --------------------------------- ---- -------------------------------------- ------------ <br /> Disposal Field (Specify Requirements).___..., l <br /> ----------------------- <br /> - -------------------------------------------- ------------------------------------------------------------------------- ------------- -- ---- <br /> ------------------------------------------------------------------------------------------------ <br /> --- -------- - ---------- -------------------------- <br /> f <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 /> By------------------------------------------------------ - ,,�0� �j� Title---- z`" '�` ---- --------------- <br /> (If other than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- r�.. DATE. <br /> DIVISION OF LAND NUMBER ------------------------- - --------- --------------------------------------------------------------DATE.------------------------------ -------- ........ <br /> ADDITIONALCOMMENTS------------------------------------------------------- ---------------------- ---------- ----------- --------------------- --------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------------------------------------- ------ --------------------------------------------------- <br /> Final Inspection by:----------�-- ---- ---------------------------------------------------------- ---- ----------- Date.. :.�.�----`--------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />