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1 <br /> FOR OFFICE USE: k0l", FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------ <br /> (Complete in Triplicate) Permit No ... .:-n. -#_ <br /> -------------------------_ <br /> ......... .................... <br /> ^" <br /> Date IssuedlD-_-�-�= �' <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. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION. _ .....CENSUS TRACT................ <br /> Owner's Name.. ....... :-... = Phone... :.... <br /> Address - . ------.... City zip = <br /> r.r•.. <br /> Contractor's Name........ <br /> License #--- ?- �..Phone...�j�G <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercials' Trailer Court ❑ <br /> Motel ❑ Other------- ---------------------------- <br /> Number <br /> ---------------•----------Number of living units:--- ............Numbe'r of bedrooms............Garbage Grinder..-.-.-. ..-Lot Size.- I <br /> Water Supply: Public System and name- ........................................ ...... -------------------- --•-- ---------...-----......------ --Private, <br /> ,t <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ i <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 Size - ------------------ ----------------------------Liquid Depth.-- <br /> Capacity...... ............ .Type-----•----... -- .-Material--------------------------:No. Compartments- ------:...... ...... ....... <br /> Distance to neatest: Well............. ................. .........Foundation---------- . ----------...Prop. Line------------.---_ ------ <br /> F <br /> LEACHING LINE [ J No. of Lines.......--........... ...Length of each line ------------------------ ---Total Length . .........---........ ...... <br /> 'D' Box-----..:..•:,Type Filter Material.............. Depth Filter Material......................---.--------------.---.----.------....... <br /> Distance to nearest: Well----------------------------Foundation...------------.------_-----Property Line.... <br /> SEEPAGE PIT ' [ ] Depth-----------------Diameter.------------------ Number_------------------------------ Rock Filled Yes ❑ No <br /> r Water Table Depth---------- Rock Size.-..-------------------_---------:............. <br /> Distance to nearest: Well.-------'.--.------_�......................Foundation---------_.......-......Prop. Line.-..-.------------.-------.`�! <br /> REPAIR/ADD€TION (Prev. Sanitation Permit#.-------_ ------ Dote_......:-------------- -- --------------- <br /> ----1 <br /> Septic Tank {Specify Requirements)......... <br /> / --------- --- <br /> Disposal Field (Specify Requirements).... G�-sem-- - .-.....� j 1: - ---- <br /> {f <br /> -------------------------------------------------- ----................................'---------------.------------------------------------....------..........................:-------................ f <br /> ----------------------------------- ------------.5- el------•--- .----------------- -...._:..� ` <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 Son Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certifythat in the tf` <br /> performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to beco ubj ct to rkman' Compensation laws of California." <br /> Signed- Owner <br /> ---------- -- ----- -------- ------- <br /> By-------------------- -- -----------a <br /> - �� <br /> Title. ' ---------------- -------- <br /> {I other than owner) <br /> F R DEP RTME T USE ONLY F <br /> APPLICATION ACCEPTED BY Y �� R"� -------- .... . DATE.......P1 .�.617e...- -- <br /> DIVISION OF LAND NUMBER. `......:....... --- ..._-- ----------- ------. DATE. - w <br /> ADDITIONAL COMMENTS....:........ --- ------------------------------------------------------ ................ <br /> ---------------- ----------------------- ........-.......................................-..----- --..... ------------.......- --- ---•--------------....---... ........... ...-.............. . ........ <br /> -------. --:------------------------ --------------------------------- - -/---- L----- ----- -- ......% , <br /> Final lnspecFion by:_ --..- - . Date.----ld_Zli1-7.�....... <br /> ----------- <br /> /b` .... <br />,EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas zia�y aev. ���a sm <br />