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FOR OFFICE USE: FOR OFFICE USE: <br /> _ APPLICATION FOR SANITATION PERMIT g <br /> ------------------ -------- _ Permit No._77.7 �l <br /> (Complete in Triplicate) <br /> -- ------------------ -- <br /> --------------------------------- <br /> Date Issued-_ <br /> •---•-- --------------__..------_ _ ---------------- <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCTIONu Sr�r�' <br /> Wax ------------- ----------------------CENSUS TRACT.----------------- ------------- <br /> Phone----------------- <br /> ------------Phone----------------- -------------------- <br /> Owner s Name-- <br /> ---------------- <br /> ------------ ---- - --- ------------- - City----- Q�� ZIP <br /> Address------------- -�� <br /> .� <br /> Contractor's Name -License #_ zzG Phone------------------------------ <br /> `U <br /> Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ 10) <br /> Motel ❑ Other---------------------------------------------- <br /> Number of living units:------ __--.._Number of bedrooms._ Garbage Grinder.-----------Lot Size________________________ -------------------- <br /> Water <br /> --------._ __.--.-.Water Supply: Public System and name----- --------------------- -- --- ---------------------------- ­--------------- -----------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat [_1 Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan y 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: (No septic tank orfs`eeepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC/TANK [1� Size- -� _ -� - -------- - ---------Liquid Depth.1 -------------------- <br /> Capacity_.f fype. '.Mataria!_ �'u- ---`--No. Compartments------z----------------------- <br /> Distance to nearest: Well p_____f -------------------Foundation._/4 -_--.--Prop. Line------ --. ----_______..._ <br /> LEACHING LINE If No. of Lines---------__ -----.Length of each line.--.-Y'p/� ------.Total Length.____��?G ____________________ <br /> r - N <br /> D' Box----f ------Type Filter Material-----.5-�------Depth Filter Material------ -------.--------------------------------------- -- <br /> Distance to nearest: Well__---t.0-d.-P`-___.Foundation_.._.. -a�_--______Property Line--------- _ _____ <br /> � P Y <br /> SEEPAGE PIT [i Depth_.��Diameter.- 3.3-�-----Number--.,.___- ___.- _.--.- Rock Filled Yes [ No <br /> lov <br /> Water Table Depth-------------- ----------------------------- Rock Size if �� <br /> Distance to nearest: Well----.__ .M�________________Faundation___fG' --__.Prop. Line___. -- - -. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date.__.-.---------------------------------------- <br /> Septic <br /> _____------ ---- ----Septic Tank (Specify Requirements)------- ----------- ------------------------------ --------------- ---- - ----------------------- <br /> Disposal Field (Specify Requirements)---------------------- --------- --------- --------------- ------ <br /> ------------------------------- ----------------------------------------------I---------------------------------------------------I------------------------ ---------------------- ------------------- <br /> --------------------------------------------------------- <br /> ------------- ---- -------------- <br /> (Draw <br /> -------- ---- <br /> (Draw existing and required addition on reverse side) <br /> 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 become subject to Workman's Compensation laws of California." <br /> Signed-------------------------------------- -- ----------------- -----Owner <br /> Title. <br /> ----------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY // <br /> APPLICATION ACCEPTED BY------- -'-__-- -" --- -. DATE---- _fib --�--------------------------- <br /> -- ------------------------------ --------------- <br /> DIVISIONOF LAND NUMBER.--------------------- - ------------------------ --------------.---.DATE------------ ---•--- ------ <br /> ADDITIONALCOMMENTS------- --- --------------------- -------------------------------- ----------------------------- <br /> ------------------------------------------------------------------------------------- ----------------------------------------------------- --------------------- --------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - <br /> -- -/- --------------- -- --------------- ----- ------------------------------------------------- <br /> ------- - --------------------- <br /> Final Inspection by ! Date-- --------------- ------------------ <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f8s 21677 REV. 7/76 3M <br />