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k A 4 <br /> FOR OFFICE USE: 7�—T`CrR OFFICE USIA: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> {Complete in Triplicate) Permit No----------------.------ <br /> - - <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---------------- -- ------- ] <br /> ------------------ -------------------- ------------n-------CENSUS TRACT--------------------------- - <br /> Owner's Name ! .�. <br /> = ---- ------- --- ------- 1—--------- Phone--------------------- ----- <br /> Address - -- - ------- -------- --------- ----------------------- ------ --------------------City-------�------ W-------- ------ ---- ---zip---- <br /> - <br /> Contractor's Name------- --------------------- -------------- ---------------License #------1---- --------,-------Phone ----------------------------- - <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------------------------- <br /> Number of living units:----------------Number of bedrooms------------Garbage Grinder.. <br /> ----------- Size_______________________________ <br /> Water Supply: Public System and name-------------------- --- -------------------------------------------------=----- ---------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt[l- Clay E-...Peat ❑ Sandy Loam ❑ 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 seepag4rpit'permitted if;public sewer is available within 200 feet,} <br /> E <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size...!,�n---{--------------------------------------------- __Liquid Depth -- ----------------------- <br /> Capacity-- --------------------Type.- ---------T---------Mate.rial------------ -------------No. Compartments------- ------ <br /> + -------------------- <br /> Distance to nearest: Well------------------------------------------Foundation--------------------------Prop. Line---------------------------. <br /> LEACHING LINE [ ] No. of Lines--------- ----------7►Length of each line.--- ------- -i----------Total Length -_.--------------_-------._ <br /> 'D' Box.-------- -Type Filter Material--------------------Depth Filter Material-------------------.-----------------------..................... <br /> Distance to nearest: Well----------------------------Foundation--_--- -------------Property Line------ --.--- _.----- <br /> SEEPAGE PIT [ ] Depth----------------Diameter -------_-------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth--------------------------------- Rock Size---------------_-------------------------------- <br /> i"~ Distance to nearest: Well-----------------------_----- Foundation--------------------------Prop. Line---------.---------_--_.- <br /> REPAIR/ADDITION (Prey. -Sanitation Permit#--- --------------- - -t.- Date--------------------------- -----j <br /> SepticTank (Specify Requirements)---------------------- ------ --------------------- -------- ---------- ---- ------------------------------------------- ----------------------- <br /> DisposalField (Specify Requirements)--- ------------------ ------ -------------------------------------- ---------------------------------- ---------------------- ------------------------ <br /> --------------------------------------------------- ------------------------- ---------------- ---------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby,certify thaf.l 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, 1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-------------- --- -- -------------------- =-------- ------------- - -.--.--Owner . <br /> By---------------------------------------------- --------------------- ----Title------ --- --- --- ----------------------------- ---------- <br /> (If other than owner) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-.-------- - -------- -- ---------------------------- ---------=-------------DATE r-.-,--------------- --- ------ -------- <br /> DIVISION OF LAND NUMBER----------------------------- -------- <br /> ------ _---------- DATE. <br /> ADDITIONAL COMMENTS------------------------ --- <br /> --------------------------------------------------------------------------------- - <br /> ------------------------------------------ -------------------------------------------------------- <br /> FinalInspection by:--- ------------------------- - - ----------------------------------------- ------------------------------------Date.--------------- --- ---- ---------------- ------ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />