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FOR OFFICE USE: ' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- - Permit No.7g-'-�'7 <br /> � �3D [Complete in Triplicate] <br /> -------------------------------- ----------- ------------ <br /> bate Issued_ . D4-2. <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/LOCATION. ._ � -. . . . - - - - ----- ------------------------------------ -- ------.-CENSUS TRACT--------`------ -------------- i <br /> Owner's Name. fid' --- ------------- ------------ ---- -- --- - Phone_.....� f_y <br /> _ -:. , - -- ---------- <br /> Address------------------- ----- _ -----------------C'tY - zip <br /> Contractor's Name S-------- -- -! _ "License # ?_ _r � Phone <br /> --- ----------- <br /> Installation will serve: Residence Apartment House.❑ Corhmercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------/- ------- ---------------- / <br /> Number of living units:____...-.____-Number of bedrooms..__""_Garbage Grinder------------Lot Size----tP.Q_ _�------------------------------------ <br /> Water Supply: Public System and name----- ------ ---------------------------------r----- ------------------------------------------ ---------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe i�L 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 if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] _ --Size------------------------- ---- --------------------------Liquid Depth--------------------------- q <br /> Capacity----- ---------------Type-----------------------Material----------.----------------No. Compartments-----------------------y----------- G <br /> Distance to nearest: Wei- Foundation._ _,•...- ---.Prop. Line----------- <br /> --------- <br /> LEACHING LINE [ � No. of Lines------------------------- ---Length oil each'Tina.-----------------------------Total Length--------------------------------- <br /> ------- <br /> �:. <br /> 'D' Box_______--_'__Type Filter Material.._ t_____Depth Filter Material_____ ________________________________________ <br /> µ� <br /> Distance to nearest:-Well______________ ___.Foundation____---__.___._________.___Property Line.- -----------------------------—_ <br /> ti <br /> SEEPAGE PIT [ ] Depth------ X pit mtrter.----------- -------Number"---------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable l7epth„%x---------------------------------------1----------- Size------------------------------------------------ <br /> i <br /> Distance to nearest: Wel]----------------- -- -------�---------Foundation-------------------------.Prop. Line--------------------------- <br /> j :�._--•__.-.-.�. <br /> REPAIR/'ADDITION (Prev. Sanitation Permit#----------------------------------------------------Date---------------------------------------------- <br /> Septic <br /> .________.__._______.._.._____--_--..._.__ -Septic Tank (Specify Requirements)-- ------ { ---------- ------ ------�------------------------ ---- --------------------------------------------- <br /> bisposal Field {Specify Requirements} P ---- ----------------------------- <br /> -- <br /> ------------------------------- <br /> -------------------------------------------- -------------- - -------------------- <br /> --------------------------------- <br /> -- ------------- <br /> �. <br /> (Draw existing and required addition on reverse side), <br /> 1 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'emplay any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed------------------- <br /> --- - --------- ------- ------ -- ---------------------Owner <br /> �JJ � ~... ---------------------------- - ----Title.---- ---------- t --- ------:--- - <br /> BY--------- --- ----- -.- ---`------- - <br /> of other than owner) ~` <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-.-__ <br /> - - --DATE `-- ==la - ---- <br /> DIVISION OF LAND NUMBER------------ -------------------------------- -------------------------- ?--------------------------------DATE. ---------------- --- ------ <br /> - <br /> ADDITIONAL COMMENTS--------------------- C' <br /> ---------- <br /> F ---------------------------------- <br /> ------------------______________________________________________________________________________________________________________________________________________________________ _______ <br /> _ <br /> Final Inspection b ---------------- --61------------ -- -------------Date �� - -- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ,J4S 21677 REV, 7/76 3M <br />