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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- ----- ---------- ------- --- ----------------- - . ' � Permit No.----7 <br /> ,. 't. ,.(Complete in Triplicate) <br /> tiY <br /> Date Issued--- <br /> A .....____.._ --------- This Permit Expires 1 Year From bate 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 . _ S `"�`r CENSUS TRACT._-_-._---------------__--.-- s <br /> -- <br /> - ---- - <br /> I Name.-------- - - -- --- -----=-------------------- -------- --- Phone <br /> --- ----- - -- - --- <br /> OAdd ess Cit � - ---- ----- zi <br /> l - -. --- --- Y P <br /> Contractor's Name t - License # -- / Phone 7_ ------------- --- ---- <br /> Installation will serve: i Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> t �.. ...�. . .,, Motel ❑ Other------- ------------ ,� <br /> Number of living units:__'---- .---Number of bedrooms---/---Garbage Grinder------------Lot Size __7----------------------------- I <br /> Water Supply: Public System and name__________ ___ ' '_ '_-____-_________--_.-.Private Z_=M <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam Cldy,Loam <br /> 4 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 TREATMENTSEPTIC TANK b <br /> [ 1 [ 1 Size------------ ------------- --------------------------------Liquid Depth.--------�------------------ <br /> Capacity---------------- ----Type-------------- -----.-Material---------- ---------------No. Compartments--------'------------------------- <br /> r Distance to nearest: Well------------------------------------- ==-•-Foundation--=-----------------------Prop. Line.------------------------'- <br /> LEACHING LINE [ .} No. of Lines-------- of of each fine.__-__-_.__._-__._____-_-..Total Length;______._-..__.___-._-___-__-_-_----:.. <br /> 'D' Box--:---------Type Filter Material-------------------..Depth Filter Material-------------------.----------------------------_--------------. <br /> Distances,to nearest: Well----------------------------Foundation---_-------------------------Property Line-----------_----------------------- <br /> SEEPAGE PIT [ ] Depth____________....Diameter-------- __.__-_Number-_---_-_-_--_-_________-_____ Rock Filled Yes ❑ N <br /> WaterTable Depth_-_-_-----------------------------'------------------Rock Size------------------------------------------------ <br /> ✓j � i - <br /> Distance to nearest: Wella"------------------------' Foundation--_----------------------.Prop, Line---------.--------------- •J <br /> REPAIR/ADDITION (Prev. Sanitation Permit#___________________ _ Date----------------------- ______:____-__.__) <br /> Septic Tarik (Specify Requirements) <br /> -------- ------ ---- <br /> Disposal Field (Specify Requirements]------------ -------- � � ) --------------- ----------- -----=------------------------ . <br /> `--- ----------------------------- ---------- -------- ----t----- ----------- --------------- - ------ ------------- -- -- ------- ---- ----------------- <br /> c iI <br /> (Draw existing and required addition.-on reverse side) <br /> I hereby certify that I have prepared this application and that the W6rk 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: ce <br /> t1 <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 beco ub[ ct to Whrkmaps Compensation l .ws' of-Calif ornia:"---.,-.� <br /> 5 <br /> ---------- ------- <br /> OwnerSigned <br /> By-- -- _ -....._ Title---- <br /> {---------- <br /> (If other th <br /> ner) <br /> FOR DEPARTM -U ONLY <br /> APPLICATION ACCEPTED BY.............:..._. -------------------------------- W' i `-- -` <br /> -- _ �- - -�=: � _�_-- =DATE -'.- -.�----------------- ------`---=---�'- <br /> DIVISION OF LAND NUMBER-------------- I ! � ---------- <br /> ADDITIONAL <br /> � <br /> --- DATE: ; = --ti----- ; <br /> ADDITIONAL COMMENTS---------- ----•------------------------------------ ----------------- - ------- ------------------------------------------•-------------------------------------- <br /> ------=-- - --- ----------------- --- --------- -- --------- ----I---- -- ----- -- ------- ------------------------------ ---------------------- <br /> ------------------------------------------------------------------------------•--------------- ----------- ---- -------------- ----------- <br /> -----------------------------------------------------.---------------- ------------------------------------------•----------- - � ------------------------ <br /> ----- -- -- ------ 7 <br /> FinalInspection bY=--------------------------------------------------- ---`---------------------------- --- - ------- _-Date-------i_.� --------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH RIOT F&5 21677 REV,7/76 W <br />