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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> (Complete in Triplicate[ d2 C-77 <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 /> f C { _�..•. .---CENSUS TRACT------- ---- ------------------- <br /> JOB ADDRESS/LO TION-- �� �...--- { . . --- <br /> •------------ <br /> Owner's Name... <br /> ... <br /> Address f r .1.. ...---....---....--ZIP ... <br /> ---- --- --- ,s <br /> ...�- <br /> Contractor's !- .. ? Phone----------- <br /> > --f .._ x--------------License .. <br /> installation will serve: Residence e5l,� Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> j Motel ❑ Other------ ------------- --------...--------••- <br /> Number of living units-------1-.....-Number of bedrooms-.- ---.Garbage Grinder-----•-.----Lot Size------ ---•.----- .•------- -------•------ - <br /> Water Supply: Public System and name---------- ----- • - -------• ---- .-...- .------ •-------- -----_----- •---- ._--- - •-----------------...-----11- <br /> __..._Private <br /> Character of soil to a depth of 3 feet: Sand ilt❑ --Clay❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> El <br /> ❑ 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 see age pit permitted if public sewer is available within 200 feet,) r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size -�- �•f�----�---- ' ' <br /> - - quid Depth.-- -•- •---- <br /> Capacity'.19-s:P----•-.Type- Material__r �`,�C--� - -lNo. Compartments__...-_ ------,------..-i <br /> I ----•--Pro Line " ► . <br /> Distance-ta.nerarest• weu... v Foundation_....- - otal- _ P' ---_--_ ....--- ..-.Length of each line--••----��'�---�--...__:�otal-Length..-.;__�.-�=a-.�..- . <br /> LEACHING LINE [ ] No. of Lines.---- _�-. <br /> - <br /> p' Box-_I----.-Type Filter Material...-_-5-Z. .._Depth Filter Material.._----�.$ � ........ r.' - <br /> - -- -. � _ Line. -- <br /> �# -Properrrty --- ------•-•--- <br /> Distanceto nearest:Well.-.�-��-�..--=.Foundation.---...-►_E?.. _ -...__-- <br /> SEEPAGE PIT [ Depth.-- s Qiamerer.---- -.-.---Number--------_ .._.------- ---- ,� Rack Filled Yes 1 No❑ <br /> �! y <br /> Water Table ifeptir...... ...._ - --------.:.�----Rack Size.--- .. .�.X-_� ----- ...-___...-----..._ <br /> ---------------Foundation.--___.1.i1__ --------Prop. r=----.-.----- <br /> Distance to nearest: Well._-__-__..-X-a'U--� <br /> -- -- ---•-- Date--- ••-----=- ------- ------- ---- --) <br /> REPAIR/ADDITION (Prey. Sanitation Permit#__.----.-------_--•------------- - • <br /> Septic Tank (Specify Requirements)-----------------------------------.------------------••-------------....------ <br /> Disposal Field (Specify Requirements)------------- •------ --- -- ........... --- <br /> •--------••-------------.....-----.. ...-----.--------- ------• ---- • -----_--- .........-- •---_-. ------•-•- ------• ...- <br /> (Draw existing and required addition on reverse side) <br /> 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. Norse owner or Iicensed 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 imanner as <br /> to become subjoct to Workman's Compensation laws of California." y� <br /> Signed---- --------.. .__..-..-----. ----- --.._ Owner <br /> ---_-------- <br /> (lf other than owner[ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__----- ._ -.-- ------------• - • ------ DATE � ,.. <br /> DIVISION OF LAND NUMBER.--- •-------------------------------- ••- -•--------....----- - -• - • <br /> ----------------- ...........DATE--------- _------------- - ••---------------- <br /> ADDITIONALCOMMENTS.-------_---- -•--------• ---•.-------------------------------------- ------ -•---------------•---- _------•---- <br /> ------------- ------:__:_ =::�::: Y::-: :::: __ _---::_::_-_I- --1. -=:::: - / _ �: .:::: __ <br /> Final Inspection by- --------- <br /> ----....-------- ------•------- •----••- ------- <br /> Fd.5 21677 REV.7118 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />