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FFOR OFFICE USE: <br /> OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - ---------------- ................... Permit No. r .... <br /> (Complete in Triplicate) <br /> Date Issued-. ...... <br /> �--�-�j <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. 549rd existing Rules c)nd Regulatio <br /> •� .ice <br /> ... ENSUS TRACT. <br /> JOB R. ---- �f/ <br /> Owner's Name.... .. . ... f...... ..---..._Phone----.............---- <br /> Address---- ---- .. �.' a/�1. ?cG-�--City � -" .. zip <br /> Contractor's Name...... ------------- Liceclse �� 4/ Phone�� <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 /> J 4 : <br /> Water Supply: Public System and name.- ............. f ' .___Private <br /> ---•-- ----- - <br /> Character of soil to a depth of 3 feet: Sand 0 Silt Clay ❑ Peat ❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe ill Material, If yes, type................_...... . <br /> (Plot plan, showing size of lot, location of system in relation to w4lls, 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 [ ] S•sze---------------------•--------------------- ---------------Liquid Depth----------,-------- --- <br /> Capacity-- .- TYPe.---- ..'.......u.Material --------:No. Compartments.. --- ------ <br /> Distance to nearest: Well---------------------------`-:-.-...........Foundation-_,__-.-- - --. ........Prop. Line.... ----- <br /> LEACHING LINE [ ] 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......-------.---.---- --- U <br /> SEEPAGE PIT [ ] Depth........ ..Diameter----------------`._.Number-----------------------.-------- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth ---------------- -------- -- -- ---- ------..........Rock Size—------- ----------- --------------------- <br /> Distance to nearest: Well-------------- ......Foundation..........-----...........Prop. Line-------..------ ----------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#._.-------- ----- ----- ---------Date----....:----- ------.- --- ----------) <br /> . lO- <br /> Septic Tank (Specify Requirements)-------------- --- -- - -----.....------. ..—....._ � - <br /> Disposal Field (Specify Requirements). ^ <br /> . •........... . . . ............ ............. - --- <br /> i .......... ------------------ <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- i <br /> "1 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 Compensatioln laws `of California." <br /> i Signed;.-. ------- ..._ Owner <br /> � ------ - �- � Title --- ........... .... .�-- --..... -�-- •--- <br /> By..----... <br />' (If other than owner) <br /> FO DEPA MENT USE ONLY' <br /> "^ -- ----DATE � -f-3---�9 <br /> APPLICATION ACCEPTED BY_....:. ......... .. ......... -- . ....... -------------------- <br /> DIVISION OF LAND NUMBER_.... .......... DATE... <br /> ADDITIONAL COMMENTS--- ------ ----- --- ................. ...................................-------------- - __ --------- -------...._.......... <br /> -- <br /> t _..._.... ------- ------ - --- ----------- ------ - - -------- - -- -------------- --------- ----------- •------------- <br /> .... ..................... .. .........----- . ... ---.. ------ -•----- <br /> ---------- •------ - - -- - --- - ----- <br /> Final Inspection by: ..... <br /> We �... <br /> i EH 13 24 SAN JOAQUIN LOCAL HE LTH DISTRICT F&S 21677 REV. 7/76 3M <br /> -7 G au•e o C V <br />