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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................... . <br /> (Complete in Triplicate) Permit......... ......................-------- <br /> ------ - Date Issued--- <br /> -------------------------------­­...................... <br /> ssued-........................................................... 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 /> G} ` <br /> JOB ADDRESS/LOCATION... ------.CENSUS TRACT. ------_---- ------ -------- <br /> -..---.��.�:�.�- ----�"....V..l. ------------- ------------ <br /> --- <br /> Owner's Name...... � - -- -. �'t►rlC�-�------------ -------- --------- <br /> Phone.----_------------ -- ---- <br /> Address............... ....-�ZO.3.19....... Q ........ Cit ZiP ._. <br /> Contractor's Name.- _.. Q.�p,_`. .._..__.....License #--!2�.f.. ., _9-._.Phone �- -- <br /> Installation will serve: Residence EPApartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other - ----------- ---- - ----------- - --- - <br /> Number of living units:-..!..---------Number of bedrooms--.-,....Garbage Grinder.....---.... at Size----. "e'"----.---.—--......... - <br /> Water Supply: Public System and name. .... «. - Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe�7 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,) . Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------- ----- ------------•--------------------------------Liquid Depth... <br /> Capacity....-- Type-------------......._.Material...-•----_--------------No, Compartments----------------_------------- <br /> Distance <br /> ...-- ._.-..---_------------Distance to nearest: Well -----------......... -- -------__-------Foundation------- -- . ------.----.Prop. Line-------------------------..-. <br /> LEACHING LINE [ ] No, of Lines............................ � <br /> .Length of each line_----------------------------Total Length - -----------.....-.---..--------- <br /> 'D' Box- --- -....Type Filter Material-.-_- - -----------Depth Filter Material.-.---------.------.---------•................. <br /> ..__-.------ <br /> Distance to nearest: Well............................Foundation-------------------------...Property Line.....----- -.---------.. <br /> SEEPAGE PIT [ ] Depth................Diameter.......-----------.Number----------------------.--------- Rock Filled Yes ❑ NOTT <br /> WaterTable Depth------------------•- - ----------------------------------Rock Size--.,. --......... ------- -- ----------------- <br /> Distance to nearest: Well-----------------------------......---------Foundation---------. --.....Prop. Line-------------- -- ------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------- -------- ..-------Date................................ -...-..--.--) <br /> Septic Tank (Specify Requirements) .......... -- N----------- <br /> jDisposal Field (Specify Requirements)-- --!'f ------ --1 l - <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 /> 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 becom je t to rkm 's Compensation laws of California." <br /> Signed '� 1-... --Owner <br /> ---------- --- ----- ------- ------- <br /> By----------------------------- ��'"`� " -- -------- .-------- -- --Title...._ .. -. .. <br /> (If other than ow er) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- _.-- -_.-- --.--- .-..--_-DATE .--- '.-��-..-$............. <br /> DIVISION OF LAND NUMBS M ------- --•---- --- - --.DATE --------- ------ ---- -..- -------------- <br /> ADDITIONAL COMMENTS__.... ----- ---------------------- --- --- ----------- ----------- -....._..... . <br /> --- ------------------------------------ ---------- ...... <br /> ...................... . --- ---- .------ ..................... <br /> . <br /> ------------------------- -------- - - g --------.-- --------- <br /> Final Inspection b Date .�--- - -- --- --------- ----- - ----- <br /> y:.. ---------------• --------- - - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21577 REV. 7/76?" <br />