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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �7�_/�� <br /> --------------"------ - Permit No.---------- -------- <br /> lComplete in Triplicate) <br /> Q �,+ <br /> f <br /> ------ - --------------- - -----------, .� �. rDate"Issued-- ? <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: _ I <br /> CENSUS TRACT----------- -------- <br /> JOB ADDRESS/LOCATION -. <br /> y3 .: - ------- <br /> jP .J <br /> ' --- -- <br /> - ----- -- ---- ------- - -- Phone . i <br /> Owners Name_.__-- ' . ._ 3 <br /> Address °City _ ip <br /> t ' -- - <br /> .►t. e Phone i <br /> .--w.. -- -- <br /> Contractor's Name--- ` p <br /> `----- -Lic License <br /> # �7�5--- 4 <br /> Installation=will serve: a Residence ❑.LL Apartment House.[] ,Commercial Trailer Court E]— <br /> ...�. . . ." Motel- '"��..,. � --��- --- --- <br /> ' -Other-- -- ". <br /> Number of living.units:----------------Number of bedrooms.-------------Garbage Grinder---- -------Lot,Size=-=----------------------------------------- ------ <br /> s ..... - S s <br /> ----------------------- <br /> : .PrivateWater SuPA1Y Public System and -- <br /> Character <br /> of soil to a depth of 3 feet: Sand ❑ 'Silt ❑ 7Clay ❑ ' Peat [] Sandy Loam LlClay Loam E] [ <br /> _. <br /> Hardpan ❑ Adobe Fill Materid`l__.._-_..-._,If yes, type---:-__.-,----_--------------- <br /> (Plot plan, showing size of lot, location of system in-relation-torw-ells,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,) W� <br /> PACKAGE TREATMENT SEPTIC <br /> -T..ANK= , . ; Size-`:_ ;. i € <br /> -- Liquid Depth --------------------- <br /> Capacity -4TYpa No:Compartments------------------------------------ <br /> -Material <br /> -A <br /> ndation__... --- -----`--- -_Prop. Linea------------------ <br /> tDistance #o.nearest:,Wel!_: __-_Fou <br /> LEACHING LINE I,j No. of Lines- .-=----=-------------- _:...Length.of each liria---= ::__ Total Length ------"- - --------------------------: <br /> D' Box.-.-----------Type Filter Material -1----------- Depth Filter Material--------------- --- =------------- <br /> r Distance to nearest: Well-'------------- ----- `----.Foundation---=------=- --------- ---Property <br /> Pr Line <br /> SEEPAGE PIT [ ] Depth_ Diameter __.---- Num -" ----- - e ❑ <br /> Number R <br /> it .. .. <br /> z <br /> ' 'oc <br /> ----- b' Rack ------ --------------------------- -- <br /> Water Table"1b_th- ° =-------- ; <br /> _ '... Distance to nearest:-Well.----------------------- - ---; ------ ----- ounatio ;--- - --------- -------- <br /> ----------.Prop. Line--------- <br /> 'F . . d � �n = <br /> ► e -- <br /> ___. Dat <br /> Se tic Tank.((Specify Requirements)_:___--__---------------. -__ ,t <br /> - --_-.h... , <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-_-._ .- • - <br /> :-33 <br /> Disposal field (Specify Requirements).------------ -------- ------------------- - -- - - -------------- ------------------ ---- ---------------------- ---- <br /> --_-. -- --- <br /> . :. - : - <br /> -------------------------- <br /> ----_--- --- - <br /> -- --- ------- ---- <br /> x. (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 thispermit is issued, I shall not employ-any person`in such mariner as <br /> to become u ject to W-prI man'*, Her <br /> 4 <br /> .Compensaticin laws of California_.." <br /> , <br /> -------- ---- <br /> Sign <br /> - ---- ----------- ---- ----------------- <br /> ! Ems' '�` i I 'r "� - <br /> C1w <br /> Y ---- - Ti <br /> f't e ��-" <br /> ! (If other'than wrier)- ; _� > <br /> -- -FOR DEPARTMENT USE ONLY <br /> - _-------- <br /> APPLICATION ACCEPTED BY �'��---- ----- - ------- --- ---DATE -----7` =v�O I <br /> - ---------------------- <br /> D ; <br /> DIVISION OF LAND NUMBER. = ---------=--------- <br /> ADDITIONALCOMMENTS-------------- ----- ` --- --------------------------------------------- -- <br /> ------------ -- - ----.--- ---- ----: --- -- ----------------------------- ------ ----- --------------------------- --- -------- <br /> ► -----y = . - - - ___._-"-"--------- <br /> . . "". -------- --------------- --------- ---------------------------------- - <br /> I ----- <br /> ----- ---------------- ------------------- --------------------------------------------------- --- <br /> T------------------------------ - <br /> --- ------- <br /> FinaInspection b - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />