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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. .. <br /> ------------------------------------------------------- Date Issued3. <br /> ---------------------------------- --------------- This Permit Expires I 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 --------- /- �Ze ----- CENSUS TRACT. <br /> Owner's Name ---- ------- --- - r=r Phone <br /> ------- _ <br /> Address--------------- -— -----------city_- <br /> ! - -------------------- O--------- <br /> --- -- -L.Q- --- CitY----l.--,�-",�„�- ----Zip-- - <br /> - ------ -------- <br /> Contractor's Name-------- --------' `~. License # 22.Z Phone <br /> Installation will serve: Residence ❑ Apartment House.D 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---------------------------------------------------------------------- --------------------- ------------------------------ Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Laam (Clay Loam ❑ <br /> .�_ ..� <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 /> it <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_.____.____.______.._... <br /> Capacity---------------------Type-----------------------Material-Y-----•--=- -------------No. Compartments----------------------------------- - <br /> Distance to nearest: Well................. _:...------Foundation ------..Prop. Line---------------------------- <br /> LEACHING LINE [ ] No. of Lines-----------------------------Length of each line------------------ Total Length---------------------------------------- <br /> 'D' Box------------Type Filter Material--------------------Depth•Filter Material-------------------.-------------------------------------------. <br /> Distanceto nearest: Well----------------------------Foundation-----------------------------Property Line------------------------------- --- <br /> SEEPAGE PIT [ ] Depth----------------Diameter. Number--------------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Well----------------------------------... _,__Foundation__...............-.-......Prop. Line.......--_------- <br /> - -------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----'?. ..` .- ......-__- _.__._.Date.__. _13..x_.7.��......... ) <br /> SepticTank (Specify Requirements)--------------------------------------------------------------------------------------------------------------------------- ------------------ <br /> Disposal Field (Specify Requirements)----- `^ - ' �`--�^- <br /> ro---_ -, r---I----- ----------------- <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 /> "1 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---------------------------- --- ------ ---- , ='_" Title -14 - -------- --- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------. --------------------------- --------------------------------------------..-.DATE--- <br /> DIVISION OF LAND NUMBER------------- -------- - ---------------------------------------------------------------- DATE--------------------------------- ---- ---- <br /> ADDITIONALCOMMENTS----------- ---------------------------------------------------------- -------------------------------------------------- ----------------------------------------- <br /> -------------------- <br /> ---------------------------------------- <br /> ------------------------------------------------------------ - - --- -- ----------------------------------------------------------------------------------------- <br /> Final Inspection by=--- � S Zi���------------------ ----- <br /> -Date <br /> EH 1.3 24 SAN JOA UIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M <br />