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FOR OFFICE USE; FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> (Complete <br /> (Complete in Triplicate) ' <br /> ------- ------------------- --------- <br /> k Date Issued.:--f.�1'17!1� <br /> ..........................................:---------..... This Permit Expires l Year from bate Issued <br /> Application is hereby made to.the San Joaquin Locate 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........ ......... ........... . ...A....--------- -------------------- .. -------- <br /> CENSUS TRACT.---------------- ---------- <br /> --- <br /> ame ..Iet> .. .... Phone... <br /> � 'P� <br /> Address � ........ A � - - . .... <br /> t <br /> l� License # Phone = <br /> Contractor's Name ------------------------- - -------------- ----.---.._....-•---- ---- ............. <br /> Installation will serve: Residence Apartment House ❑ 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 Ik <br /> Character of soil to a depth of 3 feet: Sand 2 Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <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 /> NEW INSTALLATION: (No septic tank or seepage-pit permitted if public sewer is available.within 200 feet,) ylh j <br /> s pox � x <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [�,] Size . ...:................--------------------- _ Liquid Qepth.._---------- <br /> CapacitY �2bC7 Type_ =D ee.�T....Marerial_� zJ •------.:No. Compartments.. ��- l <br /> Distance to nearest: Well_=..._....L....f-.....---_.../__......I=nundation-----�a� .- ...:...-.Prop. LineJ---�--•------------��' <br /> I _ t M <br /> LEACHING LINE [ ] No. of Lines ----.-: __. . Length of each line - ---------------- ---Total Length ------ . ---.------� <br /> --------- <br /> 'D' Box---,.j...- Type Filter Material---?. I .-('"__..Depth Filter Material--------- -------.. - ------ <br /> 01 <br /> Distance.to nearest: Well--- �'----- ----------Foundation------------------------- <br /> Rock <br /> --.--- ----- ------Property Line...--S. <br /> f r j r <br /> SEEPAGE PIT [ ] Depth.......... .....Diameter..-- ......Number--- --------------------- Rock Filled Yes ❑ No ❑ <br /> f <br /> Water"Table Depth----------------••--------------- ------------------------Rock Size... ------ -------------------- <br /> +' Distance to nearest: Well--------- ------- . Foundation.------ - ------ - .....Prop. Line --- -------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------_------- -----.__ __Date ..... -------------............ ) <br /> Septic Tank (Specify Requirements).--------_-_- •------------------- - ------------------------- ----- .------- <br /> Disposal Field (Specify Requirements) ...................•. ----------- -- ----------- - -- ---...----•---- --------- ------ <br /> ------------------------ <br /> i -------------------- <br /> " _...._.__._.._.._._..___..............- ..---------- <br /> .................................................................................:......................................"'_ _____-... . <br /> j (Draw existing and required addition on reverse side) <br /> I <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 became subject to Workman's Comp sation laws of California." <br /> E ....Owner <br /> ' Signed- .. ...... <br /> ______ _ Title------------------------------ -------------- <br /> By-------------------------- <br /> (if other than owner) <br /> �®REPARTMENT USE ONLYAPPLICATION ACCEPTED BY-----------......- ------- .--- --- .... <br /> DATE ..G.--2-7:.-77� <br /> TE <br /> DIVISION OF LAND NUMBER.------------------------ ------ ---------------- ------------- - DA <br /> ADDITIONALCOMMENTS ------=------- -------- -----------------------------------------------------------------------------­--­------- <br /> ...................- ----- -------- �------------------ --..........-...... •------- ......... -- ---- ..--- ...------. ------ ........... --- ...----- <br /> ----------------- ----------- ---------- .........-------- .......... <br /> U'-.. . <br /> -- --- ­­_7 -----------------­1------- ------------------------ ----------•--_--------- ........... - <br /> Final Inspection b =-- - --- -------------------------------------------- ----- ---------------Date.------- -------- -- - ......... <br /> EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2k5677 7 REV. 7 76 SM <br />