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FOR OFFICE USE: _ FOR OFFICE USE: �, •. <br /> ' APPLICATION FOR SANITATION PERMIT r <br /> ��,�� .. <br /> (Complete in Triplicate) <br /> Permit No. ._----- ----.. <br /> ------------ ------------- ...---------- y� <br /> Date Issueco4_ _`� <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 O dinance No. 549 an existing Rules and Regulations: <br /> n. , <br /> JOB ADDRESS/LOC ION_... .-. . :_ -----------CENSUS TRACT............. ..... <br /> Owner's Name - ---- ................. ............ ........... ---------------------- - ............. ----------------- <br /> Address---- - -- ---------- :.. ..._City------ ---------...:....-- ------. . -_Zip------ •-------------- <br /> I <br /> Contractor's Name_ { '-- J ;------..License #��..�I--��-..Phone---�.;������ ..... <br /> Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ <br /> Motel ❑ Other.:..... ---- -- __----------------- -- <br /> Number of livingunits: ..--. _ <br /> � ---Number of bed Garbage,Grinder............Lot 5ize.ZO.....A. . . ..............:................. .. <br /> Water Supple: Public System and name....... ...l.-. ---- . .............................. .. .....-................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. ... _._:lf 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,] V <br /> _. f' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size - ---------------------------------------- --------- ----Liquid Depths.. ...._._ ... <br /> Capacity....... .. ....... .TYPe.-.--•--- --.......... Material..------_------•------..No. Compartments.. _-- ------------ ----------- 1 <br /> Distance to nearest: Well------------------------ ----- ---------Foundation.......... . ..........._ Prop. Line......-.....-.......... . . <br /> LEACHING LINE [ ] No. of Lines ---..__.....................Length of each linEl------ ----------- Total Length ..-.__------.. - -----..-.. <br /> 'D' Box..........._Type Filter Material . ..:. ..... .....'Depth Filter Material-- --------- ------.-------------- <br /> Distanc&to nearest: Well---- ---------------- Foundation--------------------- ..._Property Line.........i;....-------.---- --- - <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 /> Septic Tank [Specify Requirements].--- ... - �..-. _. -_-...s. .- .F �... --------- ------------ ......3 ®� <br /> -�' - i <br /> Disposal Field (Specify Requirements]-...... .-- -•-.'�.Q. - -.- �.-�-- � . ............ -- -------- ------- <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 /> x� <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 t ------------------- Owner - <br /> .............. Title.--.- ---- ---- - ..... ........ - ------- .... ..... <br /> (If other than owner] <br /> lei <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY /u--_.. .. ,' DATE .-- -�--_,- - -- j <br /> DIVISION OF LAND NUMBER.------- . ...... .... DATE.... ........ ............. ......... ... <br /> ADDITIONAL COMMENTS............................. .. ---------------------- ---------- ... ...... --........ <br /> ------------ -------- ........ ............ ................... ............... ------- ............. ------... ------ . . --- <br /> _---------------------------------- ----------- - <br /> - .-- -------- ---------•I--•------------ - ---------------- ------------------ ----------- ----- - -•- -...-- <br /> Final Inspection b ..... Date ��� � <br /> y:.... - ------------------------ • - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT REV, 7/76 3M <br />