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n <br /> FOR OFFICE USE: FOR OFFICE USE: , <br /> APPLICATION FOR SANITATION PERMIT �i + <br /> ..................................... ......-_.. / ...� .� <br /> (Complete in Triplicate) Permit No.... ...... ........... <br /> ................•-- V 1 <br /> Date lssued....�.-��:�•:•- <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_. Q�.�..-,/ vr- f/ L11?4" --- ....- - ------------------------------CENSUS TRACT------:--------------- -- . .... <br /> Owner's Name. c . .. <br /> .........................Phone,, <br /> CO --------Zipr��Address r <br /> r.-. <br /> Contractor's Name_ <br /> ..t ---------- --------- -- ----- .- -License #.......-....................Phone_....-'------- .......... <br /> Installation will serve: Residence r Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> •y <br /> / Motel ❑ Other-------- ---------- - ----------------------- <br /> Number of living units:../.......------Number of bedrooms............Garbage Grinder-.-.-------- Lot Size----._.....-......_..... . .. .............. <br /> Water Supply: Public System and name --- -- ---- - -•--•-- --- - ----------------- ----------------------- ............... • -----Private ❑ <br /> Character of soil to a depth of 3 feet:,, Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ ; <br /> Hardpan;, Adobe [] Fill Material . --- ....If yes, type-..-_Ia? ..-...--- <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 { j ' ' Size-----------------/----------------°------------------Liquid Depth.-:----...-------------- <br /> TYpe.-.. Material No. Compartments..♦.. ....--- --- <br /> Distance-to nearest. Well ......... ...........- ---.--------------Foundation-------.-- - ------ ---., Prop. Line-----....---.--- - ------ <br /> • <br /> LEACHING LINE (1) No. of Lines'......LI...............Length of each line.....�Q.�:c----.-- -_Total Lengtht.__.��,.�F_...--.. <br /> `Di.Box % "L-..Type Filter Material_ .Depth Filter Material------ ------ - ----- --- --- ---- ----- <br /> T Distance,to nearest: Wel-?" -- aundatian-------- := .......Propert Line:-Ja.---).Z -.- . <br /> E -- ----------------- Rock Filled Yes, N,—SEEPAGE PIT [ ] Depth_.,,_.....Diameter'--------_--- Number--`--=--..--- � o El . <br /> :Water Table -Depth.-!-----'------------------------------ --- ..----.Rock Size---------------- - - ------------_-------- <br /> ,Distance to nearest: Well,--------.---------------- ------4_.---Foundation--------- ---------------Prop. Line--- <br /> .----.s_..•- . . <br /> REPAIR/ADDITION (Prev: Sanitation-Permit-#^--- -------------------.-------- -.-- --- ---- Date---------.............- -------.--..---.------y . <br /> Septic Tank (Specify Requirements) ~�� - - _. .. ........., <br /> Disposal Field S ecify Requirements)-- -- i :-= �G (F .: - -1 <br /> • <br /> ............. ---......---------------..,-._n._R_.:_----------`-------..------- <br /> ----------------------------------------------------------- <br /> yJ` (Draw existing and•required addition on reverse side) x <br /> I hereby certify that I have-prepared this application and that he work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of_'the Son`'.Joaquin Local-Health•District.,Home.owner.or.licensed agents <br /> signature certifies the following: <br /> "I certify that in tht• performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become b}ect to Workm s p on Eows of California." �. <br /> i r- 1 <br /> Signed ---- ------ ---------Owner <br /> By...........--------.-. Title----- ----------------- --------..------....................... <br /> ---- <br /> (if-other than owner) <br /> ..rk � FOR EPART NT E Y <br /> APPLICATION ACCEPTED EY-------- /L�?. - , �C----r------- --- DATE ... dr' . .__... <br /> DIVISION OF LAND NUMBCR.-.--. = --.. ..-..----- DATE <br /> ADDITIONAL COMMENTS.............. ... ----- -- -- ....... <br /> r . <br /> r <br /> '-__--.-.--.___--. -.- <br /> .. . ..................� . ........ <br /> ------ <br /> -.--------•----------------------- --- -----.--- --- ----.--..---._..-.-.-.--'-----------------" ..Date. ...........Final Inspection by:. <br /> EH 13 24 SA J AQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76 3M <br />