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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 6 ' <br /> --------------------------------- ----------------- - Permit No.---- - ----- - <br /> ----------------------------------------------------- !� (Complete in Triplicate) <br /> �� Date Issued--- 7 f- <br /> -------------- ------------------------------------------- <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 /> e J� j#tr 0 r-t-------------- ----------------CENSUS TRACT.----- ---- <br /> - <br /> JOB ADDRESS/LOCATION --------- ----------- ------ ---- - ------ <br /> Owner's Name------------------- .okf{�------ <t 0_041_n----- ----------- ---------------------- <br /> �/ ; ----- - ---Phone__[7_Z-3 <br /> _� <br /> City Address- ------------ -5am .- Phone Name_----------- -- ------------------ ------------------License # s <br /> Installation will serve: Residence Apartment House E] Commercial E] Trailer Court El <br /> otel ❑ Other---------------------------------------------- <br /> Number of living units:-_-__1___�.__-Number of bedrooms__-,___Garbage.Grinder----_------Lot Size_______________________---.._________.__.__________-_^— <br /> Water Supply: Public System and narrie--- Private <br /> Character of soil to a depth of 3 feet: Sand, Silt[ , Clay ❑ 'Peat E] Sandy Loam [-] Clay Loam E] <br /> Hardpan E] Adobe❑ FiII1Nlaterial..----------If yes, type-------------------------------- 4 <br /> (Plot plan, showing size of lot, location of system inrelation 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 [ ) <br /> Size--- -------- ------= ---------- - ------Liquid Depth--------------------------- <br /> 4 <br /> �Cc1 Capacity---------------------Type----------------- -----Material.-------------------------- <br /> ---- --- ---: *,,Compartments <br /> Distance to nearest: Well-------- Foundation--------------------------Prop. Line_.__--_____._____._____- <br /> LEACHING LINE [ ] No. of Lines__ _____ ______________Length of each line------------------------------Total Length----------_--_____________._.__--_-__ f, <br /> 5 'D' Box -__ ----Type Falter Material--------------------Depth Filter Material------------------------------ -------------------------------- <br /> Distance to nearest: Well----------------------------Foundation___________________________Property Line------------------------------------ <br /> r`". <br /> SEEPAGE PIT [ ] Depth----------------Diameter---- ---------------Number-------------------------------- Rock Filled Yes ❑ No❑ <br /> WaterTable D.epth---------------------------------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line_______-_________________. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-- _-----------------------------------Date_________.__________.___.________.___--__) <br /> Septic Tank (Specify Requirements)----- - ------------ f - -------- `--------------- <br /> - <br /> � �Disposal Field (Specify Recjvirementsl -------- -- ------- <br /> t <br /> ---- --- -----------------------------------------------------, ----- ---- <br /> - (Draw,existing and required addition on reverse side) <br /> I Ftereby 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 Jo6-11{uin Local Health District. Home owner or licensed agents <br /> signature certifies the followings <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 becoMAsuubjec >I <br /> to Workm 's Compensation laws X9fr California." <br /> Signed._N'z- -- ----- ----Owner <br /> BY--------------------------------------------------------------------- --- - Title------------------------------------------------------------ --------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- - - -----------------------------------------------------------DATE. ' " ------------- <br /> DIVISION OF LAND NUMBER._.___. , -._ ----------------------------DATE-------------------------- <br /> ADDITIONALCOMMENTS------ ---------- ----- - --- - -------- ---------------- - ----- ------ --- ------ - -------- ----------- -------- <br /> ----------------------------- ----------------------------------------- -------------------------------------------- ------------------------------------------ --------------------------------- <br /> ---------- -- ------ ----------- ------ ---------- , <br /> - ------ ___ f � <br /> Final Inspection by: X -_Date <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fps 217 REV. 7/76 3M <br />