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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATIONJOR SANITATION PERMIT <br /> •---------• _...... ...-. <br /> t (Complete in Triplicate) Permit Na...7 ._----...--- <br /> Date Issued.-7r/?- <br /> , ••-•-•••- ................ ............................. 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 .Nd. 549 a�nd'existing'Rules and Regulations:` 3 <br /> > �. m <br /> f JOB ADDRESS/LOCATIpN f# CENSUS TRACT......... ........ <br /> Owner's Name...-` �- '. .....�, '- �' Phone-=-- ------ --- ...".... -- ---. <br /> Address----- -•------....-- -.--City-------- ---------------- .... ..-.....Zip. - <br /> ' Contractor's Name--------. ...................-License #.--- . - - F ..Phone.. Ir�. <br /> 1 <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> r .-Motel-❑ --------- .......--- <br /> Number of living units:_--------------Number of bedrooms......--....Garbage Grinde--------------- Size------..........-.... : - ...-_--- _-.-_-.-_- ..... .. <br /> Water Supply: Public System and name.. .'-- ------------- "'' Priva <br /> te <br /> Character of soil to a depth of 3 feet: . Sand ❑ SiltE], Clay.❑ Peat E 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 /> NEIN INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) G <br /> PAC KAGE,TREATMENT [ ] SEPTIC TANK [ ] Size....... ....... .-------.-Liquid Depth.------ .---.-..--.."--- C <br /> Capacity.... .. .... .......Type---------------. ------Mate-rial---I--------------- -----:No. Compartments-------.-------•------------ <br /> Distance to nearest: Wet[--------------------- --.--- -.-. ------.--�Foundotion------.... .......--....Prop. Line------------.-.-...----- -- <br /> LEACHING LINE [ ] No. of Lines ...-- ....."--_.---.---.Length of each line---------------- Length ....-.---.-..----. <br /> -------- ---Total Len ---.----- ----------- <br /> 'D' Sox--------- -,Type Filter Material',"----- ------ -- Depth Filter Material.........---......-.--------------------- -------.-------------- <br /> f <br /> Distance to nearest: Well----------I....... Foundation--------------------- --Property Line---------------.---"..--- .-.....-. <br /> ' SEEPAGE PIT [ j Depth.... ......... Diameter....._-----------t_..Number. .--------_----------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth.--........ •-----.....-•'----- ----- -------------- --Rock Size.......... .............. ................... <br /> Distance to nearest: Well------------ -`--------------............Foundation-- .............".Prop. Line..............___-"----.-. <br /> REPAIR/ADDITION {Prey. Sanitation Permit#-----................. - `-.- ` Date_---...............--- ...... <br /> Septic Tank (Specify Requirements) ..... ...... -------------------- <br /> Disposal <br /> ---- ---------- <br /> Disposal Field (Specify Requirements)-..-- -- - ----------- - ----------- - --------------------- <br /> -------------•-- - - <br /> ��x <br /> V.x :- <br /> --------------- -- ........ ----- <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 /> to become subject to Workman's Compensation laws of California." <br /> Signed---- . ... :----- ..-- .---....Owner <br /> :_...: Title--- -- --------------------•------- <br /> [If at er than owner) R <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEDBY .._ ----- ----- - ------ "DATE .. ' <br /> DIVISION OF LAND NUMB - ------- --------- ...DATE- -_----------- - ------- --.--- . --- <br /> ADDITIONAL COMMENTS_....................._ . --.... -- .. <br /> ----------------------- ..........-................... <br /> -------- <br /> Final Inspection by:. '�1� - .- - -------- - -----Date. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7/76 3M <br />