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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> f Permit No....-........... <br /> (Complete in Triplicate) �- <br /> , �. Date Issuecl_&.�`�..5 ?� 7 <br /> ---- <br /> This Permit Expires 1 Year'From Date Issued <br /> ----------- ------- ----- <br /> made to.the San Joa uin Local Health District far a permit to construct and.install the work herein described. <br /> Application is hereby q <br /> This application is made in compliance with County.Ordinance No. 49 and existing.Rules and Regulations: W <br /> � / <br /> � / / ... <br /> -- ..CENSUS TRACzT-ip-.-------- <br /> JOB ADDRESS/LOCATION. . .. --- ..G4 . ...... Phone-� � <br /> •77� <br /> ---" <br /> Owner's Name.--- <br /> Address--=- ---� - --� ----- ........City. <br /> 7 <br /> ri <br /> � ` -- -- <br /> s <br /> Contractor's Name............... - .... --------- <br /> "- ;- -------�- ----License #343�.��;.. .Phone.�}�.�o. <br /> installation will serve: Residence Apartment House-❑ Commercial E] Trailer Court ❑ <br /> Motel ❑ Other' - '.... .........-1-------- <br /> 7�77 <br /> Number of living units;.......-----Number of bedrooms.-..a Grinder- Lot 5ize.. <br /> --•...:........... <br /> Private-. <br /> Water Supply: Public System and name....... ......... ... ...... .. <br /> __ - ---------------. ... <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt El Clay ❑ feat E] Sandy Loam Clay Loam El <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,), <br /> PACKAGE TREATMENT ( ] SEPTIC TANK ( ] <br /> Size --.........- -----• --------- --------- ----Liquid Depth..::..------- ------------- <br /> Capacity------------ ------- Type"----•------ 1...._ <br /> Material NoyCompartments.----- ....... <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_...... . ..... . <br /> .Depth Filter Material_------ -- ------- -- <br /> _Foundation •----•--.---------Property Line ---•---- - ------- <br /> Distance to nearest: Well'...._............."""-- . . <br /> Number.----------------------•--- Rock Filled. Yes ❑ No <br /> SEEPAGE PIT [ ] Depth............. Diameter-_...-....---- - : + <br /> Rock Size. `-- -- -----­------------------ - <br /> Water Table Depth--------------- - ; <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 /> s (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 /> k 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, f shalt not employ any person in such manner as <br /> f to become subWIDW ma m en tiote laws of California." <br /> Signed.----- --- <br /> 0 --------- <br /> Owner <br /> " Title.-- <br /> ----------- <br /> (If other than owner[ <br /> r FOR DEPARTMENT USE ONLY <br /> '. ----..DATE ..' <br />