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i <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete'in Triplicate) Permit No.-___-____- <br /> --------------------------------------------------------- ,,//-iz 71' <br /> Date Issued--`f________ ______ <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 .�--- ------ - - -------------- - ---- ---- --------------------------------------CENSUS TRACT -------- <br /> Owner's Nome------ - �- ------ --- - ----------- ---------- -------------- Phone_ y` <br /> ---'._ . Cit c (--------------Z' -------------------------- <br /> Address <br /> ---- -- --- ---- - - Y ----- p <br /> Contractor's Name--- ----0-A- - - -----" ----�- -- ------------------.----------- - + ----License <br /> 17 - <br /> Installation will serve: Residence V Apartment House.❑. 'Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------.------ --- I------------------ t <br /> / GC <br /> Number of living units:______.1--____Number of bedrooms, ____Garba e Grindw ---------lot Size-.-,7..7r .--__ .__ -------------__. <br /> Water Supply: Public System and,name---- ----- ---- --- -- ---- ---- --------��---- ---------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobex 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 TREATMENT SEPTIC TANK _____Liquid Depth.---_--.___-___-_.-_-___ <br /> [ 1 [ 3 Size -----------=------------------------ - <br /> Capacity---------------------Type----------------------.Material_- -----------------No. Compartments-----------------------------------_c <br /> Distance to nearest: Well---------------------------------------:---Foundation,._;; ------------------Prop. Line__________._-.------_---___.�1 <br /> LEACHING LINE [ ] No. of Lines-----------------------------Length of each line----------------.------------Total Length.----------- ----------------.- ^l <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 /> Distance to nearest: Well-------------------------------------------Foundation-------------------------.Prop. Line------------------------ <br /> REPAIR/ADDITION <br /> -- _REPAIR/ADDITION (Prey. Sanitation Permit#-------- ----- ----------- ------------ <br /> Date - -------------------------- <br /> ------- <br /> ---------- -- --------- <br /> Tank {Specify Requirements)--l4 - !. ----------------- <br /> Septic <br /> Disposal Field (Specify Requirements)---.I '--.- _I_�____ _ ___ _ _____ __________________________ __ <br /> r <br /> ----------- '---'-` 2----------------------- ----------------------------------------------------------------------------- ----------•-------------------- --- 00---- --- <br /> -------------- ----------------------------------------------- ----------------------------------------------------------------- ------------------------------- ------------------------------------------------- <br /> {Draw existing and required addition on reverse side) <br /> 1 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 bec a bie t to Wo mans ompensation laws of California." <br /> Signed---- <br /> --- ----- - -----------'-- - Owner <br /> BY - / Title - -------- ---- <br /> (If other than owner) <br /> , 42 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- ---]... E ------- -------- ----- DATE. f t� _7p--------- <br /> DIVISION OF LAND NUMBER-------------------------------------------------------------------------------- ---------------.DATE-------------------- <br /> ADDITIONALCOMMENTS------ ----------------------------------------------------------------------------------------- --------------- ------------------------------- <br /> ----------------------- ----------------- - --------------.---- ----------------------------------- ------------------------------------------------------------- ------------------------------------------------ <br /> ----------------------------------- ----------------- <br /> Final Inspection by:.___- __ ._ <br /> - ---- ---- ---- ----- -- ------------------------------------------------------------------- - Date------------ ---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />