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FOR OFFICE USE: `fOR'OFFICE USt: <br /> APPLICATION FOR SANITATION PERMIT <br /> 77r"� <br /> - --------- - Permit No-- --------=----- <br /> �' � ' (Complete in Triplicate) <br /> -- --------------•-------- ----..__._- --- -...- --; -- - Date Issued�.:.���--'.�� <br /> ••--•--• --------- ....... --------------- This Permit Expires 1 Year From bate Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a;perrni.to construct and install the work herein described. <br /> This application is made in compliance with County.Ord'nan No. 9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.......- -I.-_`..�. .. CENSUS TRACT...........--_-.-..--..- <br /> Owner's Name ............................----------------Phone.--------------------- .... --- --- <br /> Address -------- ----- ----- - -----City................ ---Zip--- •.. = .................... <br /> Contractor's Name___ -- .... <br /> .- License # - .. +�. /....Phone--%-- -- - i 7 <br /> Installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court.❑ 4 <br /> Motel ❑ Other--..-.--. - ............... <br /> 07 <br /> Number of living units:....... --"-Number of bedrooms. Garbage Grinder............Lot Size---.-- � /l -.-.- <br /> Water Supply: Public System and name...... ' -- - - -------------------------------------------------- - ----------------.---- ---Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay d JPeat-. ] Sandy Loom ❑ 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 /> GIN <br /> NEW INSTALLATION: (No "septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENTSE PTIC TANKSize....._ .,Lf-~ - <br /> x. :�Q------•- Liquid Depth.--- '...........:...... <br /> I ] <br /> f l <br /> -. -.....Mate-rial----. fd ----.-.-No. Compartments.....�;Zl,.- <br /> Distance`to nearest: Well Foundation.--------- .._._ ....Prop. Line----__..................•. <br /> ] No. of L r f <br /> LEACFIING LINE Ines -----.t..-.-.Length of each line.-------1-.p-- --.--- Total Length'./'~1'------- .----.- �{ <br /> 'D' Box.e:-— Type Filter Material-- �-.Depth Filter Material— <br /> -`..�---------------.................. <br /> Distance•to•nearest: Well -: Foundation -.-------------_-.........Property Line ._..--- -.- ---------- <br /> � 'moi 1 �1 / <br /> Depth---` Diameter-:-. ,� Number--, --�-- Rock Filled Yes No <br /> tt11� � - <br /> �+Mo Water Tabi�'Depth--- - � 'i- ------.----.Rock Size--.------ .. <br /> r. �I(JL r ' <br /> Distance to nearest: Well-" - - ---------------Foundation Line..-.-.-. -----.--- -:_:" -. <br /> REPAIR/ADDITION (Prev, Sanitation Permit#-------------------- =..... ....._-- --.Date----------:--:---------.----.----------------_), E <br /> Septic Tank (Specify Requirements)....< ..,.__.-..... - ` 't <br /> -- - -- ---- --------- -...........---..-....-.-. , <br /> Disposal Field (Specify Requirements) - - -------------- � � j <br /> ..---- -. ---- ---- ....... <br /> --------------------- --- <br /> ------------------------ - ............. . --------------• - ---- --- ------ - - -- .---- <br /> --------- i <br /> (Draw existing and-recljirecl 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 laws of California." <br /> Signed--- ... ----- - --Owner ' <br /> By------------- Title................. }---,------- ------------ - 1 f <br /> ( f arthan owner] <br /> FOR DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED BY-- -- <br /> -------' .............DATE ..�-44'�........... <br /> DIVISION OF LAND NUMBER.--- .-.....-...�---------- ----------- - --....... .............. -------= ----------....DATE.-i-- .......--------- -.... <br /> ADDITIONAL COMMENTS--....... ......- F -------------- - - ------ <br /> - - <br /> ......-.---- -------- ----- ------------------------------------ ------ --------------------------------- --------------------------- -- -----.-I-—------------- <br /> -------------------------------- <br /> --- ----------------------------------- -•- -- ...... ...-: ---...--- _- -- .-...------..-..•--....----......-- -------•------------------_------ r ------------------------- <br /> ­----------------------- <br /> -- - -- <br /> Final In SP by:.. --.. ....... -- ------- ------------ ------------.---- - -- ............... "1 ...... _...- <br /> CH is saSAN JOAQUIN LOCAL HEALTH DISTRICT', F85 21577 REV. 7/75 3M <br />