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FOR OFFICE USE: FOR OFFICE"-OSE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............. ------- ............ 7 <br /> (Complete in Triplicate) Permit No/ <br /> ......................... . . .......... Date <br /> ..................... ........... ............ This Permit Expires I Year From Date Issued <br /> Application is hereby made to.the Son Joaquin Local Health,District for a permit to construct and.install the�work herein described. <br /> i This application is made in compliance with County Ordinance Nod. 49 and exis'tin'g Rules 'and Regulations; <br /> -------i -------- ......CENSUS TRACT.._..--- ................... .. <br /> .JOB ADDRESS/LOCATI ON --------- - <br /> Owner's Name.... ... ........... ........................... ------------- ------ <br /> --Phone..... ------- <br /> Address---------- C -- <br /> --------------------- -------- <br /> ...... .. .. ....... i ty----- ........ . I ...... <br /> f-�107 Phone- <br /> ....License -_AT <br /> Contractor's-Name........... <br /> n 1;stallation will serve: R <br /> I esil <br /> ence Apartment House E]_ E]Commercial.❑ Trailer Court D <br /> Xmotel E] Other_.. - ------__ ..............I------- <br /> I Number of living units;.............1._Number of'bedrooms--.--. ....Garbage Grinder----------!.Lot Size..................... .. ....... -------- - <br /> ...... --------- ----------- --------Private El <br /> 4L 'Water Supply: Public System an&name.. ......................... ........................................................ <br /> Character of soil to a depth of 3 feet: Sand E] Silt EJ Clay D Peat F Sandy Loam El Clay Loam E] <br /> Hardpan E] Adobe E] Fill Matericil:_ ....if yes, type--- ------------------------- - <br /> (Plot plan, showing size of lot,;",Iocation of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> N:t.W INSTALLATION: lNo septic tank or seepage "pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size - ------------------ Liquij'Depth-------------- -----------Z�A <br /> I ;--------------------- <br /> Ccipacity-_.--- --------,Type.....-•-- ------- .....No. Compartments ------- _------------ -- <br /> Distance to nearest: Well.-:------------------- -- - ­­-------..Foundation...__.. - _-..F�rop. Line-:..... -------------- <br /> LEACHING LINE No.,of Lines --------------------- Length of each line..---------------- ------ Total Length ------- ----_----------- ------ <br /> 'D' Box:.....-'---.Type Filter Material__....... Depth Filter Material............. ----------------------- ---------- ------ <br /> Distance to-hearest. Well--------------" - Foundation------------------------ Property Line....... ----------- ------ - <br /> SEEPAGE-PIT Depth:.7....... ............ ......Number -- ----------------- Rock Filled Yes ❑ NoJ <br /> ------ ' .............. --------- <br /> Water Table Depth----- .................... .---------..... Rock Size. ...... <br /> Distance to nearest: Well--- ------------ -- -----------_-----_Foundation--- ---------- ---- -.Prop. Line ........ ......... ....... <br /> ,a f <br /> REPAIR/ADDITION {Prev. Sanitation Permit#----------- -------- ------------- ---------------Date- ------------- ---...... <br /> Septic Tank (Specify Requjrem' lnts)____ . ... ...... ----------------------- ------ <br /> --- -------- .... ...... <br /> Disposal Field {Specify Requirements(.... <br /> -------------- ........ ..... .. <br /> ........... ...................... ------------ -- -- - --- ------------ ................... .. .................................... ---------- <br /> .. <br /> ------------------------------------- -------- --------------------- -­------------------r-- -----------------------••- ----------- <br /> (Draw existing and required addition on reverie side) <br /> ll!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." ti <br /> Signed----- . Owner <br /> Title__.._. ------- ------ ---- -------- ---------- <br /> By I <br /> ----------4:�. . .. ... .... . -------- <br /> (if other than owner) <br /> • F0,R DEPAR ENT USE ONLY <br /> APPLICATION ACCEPTED --- ---- ----- - 3 ----------- ............ ........DATE ...... <br /> . ............. <br /> DATE. _--------- ----- - - -------- - ---- <br /> DIVISION OF LAND NUMBER... ................... .............. ...... ­......... ...... -----------I---------------- <br /> XDDITIONAL COMMENTS......... ..................P ------- <br /> ....... ........ <br /> ----------- ----------- - <br /> --------­---------------- --- - <br /> ---- -I--------- . ........... .............. <br /> ............. ............................_.........I--------- ---------- - ......... <br /> -------------­------- .................. ...... --------------_------------------ <br /> ------------- ­------------------- --------------r----------------------------------- ------- <br /> ------ ------t.......... ... <br /> ........................... ...... ---- ----------- <br /> V, ............. --- --------- ......-------------:---------- ......... ... <br /> Pinal-Inspeciian byz.... ------- <br /> F&S 21677 REV. 7/76 3M <br /> EH 13 44 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />