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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - 3 <br /> (Complete in Triplicate) Permit <br /> No .. _____._._ <br /> Date Issued'_-l3-- <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 a d existi Rules and Regulations: <br /> JOB ADDRESS/LOC TION_ _- :. CENSUS TRACT <br /> . �'� <br /> Owner's Phone <br /> D -----_ -- <br /> Address e -- 1 -- - - -- ---- - --------------'City _ - - Zip <br /> Contractor's Name--------- . 4 ----------L'cense # _ <br /> Installation will serve: Residence Apartment. House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel'❑ Other-------'---. - ------------------------------- <br /> ----Ns__ _ --mg amts:._ _ Number,of,bedroomGarba a Grinder _, . -Lot=Size __ --- <br /> Water <br /> o <br /> 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'❑ 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----------------------------------------------------------- -- <br /> Liquid Depth--------------------------- <br /> CapacDistance to nearest: Well-e-___..____._-� . ,µ_.- . ---,----� <br /> ity.---- --- --- YP --=-=---- <br /> i -- -- <br /> aterial------------------------=-NoCompartments.--------.------------------� r <br /> Foundation -Prop. Line--------------------- <br /> t <br /> A g , -. <br /> ,_ . .,_ g.. = Y - .Total Length ------------------------=-------------- <br /> LEACHING LINE [ ) . No. of Lines_______________ ____ _ __ _Len th of each lin <br /> D' Box------------Type Filter Material-------=-------.-----Depth Filter Material------------------- --------------------------_'----------. <br /> �F. �« . <br /> Distance to nearest. Well---------------)----------._Foundation,.____.____.__________ Property Line---------------'__ :--- `. <br /> SEEPAGE PIT Rock Filled Yves Fil F •;] <br />_ -=------- ----------- <br /> Water Table'Depth.-7-------.------- ----------=------- ---- <br /> ( e .._Diameter________:_____ .__--Number__._ -�� ' � <br /> ----=----Ro'ck Size ---- <br /> Distance'to heardst: Well---------------------------------------`��Founaation--------------------------Prop. Line------ -__----___________ <br /> REPAIR/ADDITION (Prey:Sanitation Permit#-._----________________-._-.---___-_-__----__-_=:Date.-- ----------------------- <br /> ----- <br /> ______-_____--._` <br /> Septic Tank.(Specify Requirements) -.---- -- - �--' �-------------------- --------- <br /> Disposal Field (Specify Requirements(?. �/ / �= . . <br /> - ~t <br /> ___________________________ -------.-__._ .d `-: . <br /> S (Draw existing and required additiori'on reverse side)• <br /> I hereby certify that I have prepared this application and that the workwill 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: w, <br /> "I certify that in the performance 'of the work for which this permit is issfied, I shall not employ,any person in such manner as s <br /> to becom su Ie t to Wor . an's ompensation laws of 'California: ~`' <br /> a <br /> 1� _:ate r � i <br /> Signed - -- ---------------------- _ Owner *c <br /> BY= --- ^i----- Title -=---------- ----------- ----------------------------------- ------ <br /> (If'other tha ner) r sJi" <br /> " <br /> > = DE RTME US O LY.� <br /> •. <br /> APPLICATION ACCEPTED BY_�-----C,0-_6,V- --- - .DATE.--- :-"- -- i <br /> DIVISION OF LAND NUMBER_ <br /> ----------------- -- --------= =---------""---------- _Ai ----=-----------------DATE.---...-------------_--------------------------- <br /> �_ <br /> ADDITIONAL COMMENTS----------------- <br /> --------------------- <br /> -------- ---- -- ------------------ -- ------------------------- ------------ ----------------------------------------------------- -- -------.. <br /> ------=-------- - -=--- ------ -------------------- --------- -=-------------- ' <br /> ------------------ ---------------------- ------- ----------------------------------- ----,--------------------------------------------------- <br /> Final inspection by:-------- --- - -- -- -- --- --------------------------------------- --------------------Date--- - --- 1� t <br /> ------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />