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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ ----- 7�-.37/ <br /> ..-.. Permit No..--.- -- <br /> (Complete in Triplicate) ' <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 /> (JOB ADDRESS/LOCATION--- v -.5. ._ <br /> -----`--- --------------------------------•--.CENSUS TRACT--------•--------.R ....--- <br /> )(Ovrner's Name ...................... <br /> / + Phone_.. `.......... <br /> Pddress... _- Q.V�(a..I.J...-1rm..--So.., .�.,.--------------------------------------- -------------City-......c,�..------------....---..... Zip----5-S.a7A............. <br /> )(Contractor's Name.......---5���... - .......-------..License #------------------- - - Phone.-------------- -------------- <br /> Installation will ;serve: Residence Apartment House ❑ Commercial E] Trailer Court E-]Motel ❑ Other--------------------------------- • ---------- <br /> Number of living units:..... -------Number of bedrooms............Garbage Grinder--- .---Lot Size._..-..__..... . ... ... . ...... .............. . . .. .. <br /> Water Supply: Public System and name. --- .:.. - ------ -- ---- ----=----------.Private F1Character of soil to a depth of 3 feet: Sand E] Silt E] Clay [:] Peat ❑ Sandy Loam 0 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 <br /> [ ] Size---------- -- -----------------------------------------...-Liquid Depth---------------------- ----� <br /> Capacity--............--.....-Type.... ..................Material_----------- -----------:No. Compartments--------------------- ------:.� <br /> c. <br /> Distance to nearest: Well_---__............ ........... -------.Foundation...... .............Prop. Line.................... <br /> ..-.---5 <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---------.----_--................. <br /> SEEPAGE PIT ( I Depth....- ... .....Diameter.....................Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> .Water Table Depth---------------------------------------------- ----------Rock Size.................. ------------------------------ <br /> Distance to nearest: Well....................: ....... Foundation..........................Prop. Line........................... <br /> . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_-•................................ ...............Date-------•---.....---------._-------- --.-------y <br /> Septic Tank (Specify Requirementsl...-- ... n - ------------ <br /> Disposal Field (Specify Requirements) Q£( P 0------- � <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 /> Si ned %ject; <br /> = .p...............•------ -•------ ----if-----O ��tog ece s Workman's Compensation laws of Cal Owner <br /> By............................... . --- ------...._Title.-- ----------------- <br /> (If other than owner) <br /> C <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- _ ............................DATE ...-- --__ <br /> DIVISION OF LAND NUMBER ----------- -- ------ --- ..............DATE--.-............------- - - <br /> ADDITIONAL COMMENTS---------------------------------------------------------------------------- ___....... <br /> .- -- -- ...._..... <br /> --------------------------- --- .............. ----- -- ............................ ---------- -------------------------------- ................... ................ ----------- .......... <br /> ------------------------------------------- --- - -------------•-----. --------- '..-------- <br /> Final Ins ectlon b .-.--`- � . ................. <br /> -lC c --- - ---------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />