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FOR OFFICE USE: FOR OFFICE USE: <br /> t APPLICATION FOR SANITATION PERMIT <br /> ----------- `77-� y rJ <br /> {Complete in Triplicate} Permit o._ <br /> ------------ ------------------------------ --- ---- ---- <br /> Date Issued-------------------- <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. 549 and existing Rules and Regulations: <br /> �j G� ------------------.CENSUS TRACT-------------_- ----- --------- <br /> JOB ADDRESS/LOCAyTIION---------�n- 6 I { r�. <br /> Owner's Name--..-.-.-Ff----f-------- ----------- ------ --------- :.. Phone <br /> Address.--- --- -- - city----------------- -------------- -------------Zip----------- -----;--- <br /> Contractor's Name..------. T _ ­ - .�.__.- - - - License #- —0__�1 Phone---- W- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motelj Other------- ------------------ ---------------- <br /> � -_ 7 <br /> Number of living units-----------------Number of bedrooms------------Garbage Grinder-----------:Lot Size------.-____: - —--- _ ..---------..___-_ ...... <br /> Water Supply: Public System and name-- -------------------------------- ---------------------- --------- --------- h ----------------------------------------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------------------------------------------------------------Liquid Depth------ ----------.------. <br /> Capacity---------------------TYPe---------------------- Material--------------------------No. Compartments------- ------'------------------F <br /> f Distance to nearest: Well--------------- ---------------------------Foundation.-------------------------Prop. Line------------------------- _. <br /> LEACHING•LINE I ] No. of Lines -..--.--/------Length.of each line.--.-------/_.0-----------Total Length ......I_ ________-_--.------ - .- <br /> 'D' Box.........---Type Filter Mciterial--------------------Depth Filter Material------ ---.-------------------------------------------- <br /> Distance to nearest: Well.- --------------Foundation----------------------------Property Line--------------------- ------- <br /> T [ ] <br /> Depth0-AWA 6meter------------. ----Number.------- -------------------- Rock Filled Yes, ' No <br /> 1 <br /> Water Table Depth------------- ----------------_-x---------------------Rock Size----- { <br /> Distance to nearest: Well- -------/.R_4-------------------- Foundation._i_Gr...-----.-_______ Prop. Line.__!i1_11:_.------.---- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------------- Date.--------------------- ------------1 <br /> Septic Tank (Specify Requirements)--- --------------- ------------ --------- -------------------------- ----------------- <br /> Disposal.Field (Specify Requirements)---------------------- ----------------------------------------------- ------------------------------------------------------- ------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- --------------- <br /> ----------------------- ----------------------------- -------------------------------------------- ---------------- ------------------------------------------------------- -------------- <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 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 aws of California." <br /> Signed.-- Owner <br /> - - -- ------------ - --- <br /> BY - Title-------------------------------------------- --------- -------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ ---111 -_ ----- --- -------------------------------- --------DATE <br /> DIVISIONOF LAND NUMBER ------------------- ------------- ------ ------------ -------------------------------------------------DATE-- -------------------------- --- <br /> ADDITIONALCOMMENTS---- -- - --------------------------- --------------- ------------------------------------- ---- -------------------------- ----------------------------- ----- <br /> ------------------------------------------------ - ---- -------- -- ---------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- --- ------ _z ---------------I- - <br /> Final Inspection by:---- --- - ------ --- --- ---- ----- / �--��- Date ----L� <br /> EH,19 24. SAN JO UIN LOCAL HEALTH DISTRICT F&s 21677 Rev. 7/76 3M <br />