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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR'SANITATION PERMIT d <br /> (Complete in Triplicate) <br /> Permit No. I4'-- 7- <br /> Date Issued-_b_�_-_7-y--- <br /> --------------- ----- ----------------------------------- This Permit Expires,l 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 ADDRESSAOCATION,. Z- `2— e _. CENSUS-TRACx.______.-.---.- <br /> ------ ------- <br /> Owner's Name. - -- -------- one <br /> ,, L P <br /> Address. = °� - - ------ City �-�T Zip <br /> - -------------- <br /> - --------- ----- ------ <br /> Contractor's Name --- -- °`� -�--License # 3Z_ _Z-L Phone <br /> ------------- <br /> Installation will serve: Residence ❑ Apartment House.❑ Commercial:❑ Trailer Court ❑ <br /> Motel ❑ Other-___--' ----Number of living units:-----/---------Number of bedrooms----?/Garbage Grinder------__----Lot Size--------- -t - ------- <br /> Water Supply. Public System and name- ----- -------------------------------------------------------------------------------- ------------------------------- ----------Private <br /> Character of soil to a depth of 3 feet:f Sand ❑ Silt E] Clay E] Peat F] Sandy Loam [-] Clay Loom E]Hardpan V 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 seepage pit permitted if public sewer is available within 200 feet,j <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [ ] Size---.-_----------------------------------------------------Liquid Depth. --.-._----------- <br /> Capacity---------------------Type ----------------------Material-- -----------------------No. Compartments.------------------ - ------------ <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line----------------------------- <br /> LEACHING <br /> ----------- _---------_--.LEACHING LINE [ ] No. of Lines------------ ----------------Length of each line-----_------------------------Total Length -------------------------- -------- <br /> 'D' Box------------Type Filter Material--------------------Depth Filter Material--------------------------------------------------------------_. <br /> Distances to nearest: Well------------------------- --Foundation----------------------------Property Line----------------------------- <br /> SEEPAGE PIT [ Depth----------------Diameter--------------- ----Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth----------------_-- ----------------------------------- Rock Size------------------------------------------------ i <br /> Distance to nearest: Well--r-----------------------------------------Foundation--.----------------- ---.Prop. Line.-------------- _----_. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----.---./-[ ---_�_ ---------Date----- <br /> :=� _- <br /> j <br /> SepticTank (Specify Requirements)----------------------------------------------------------------------------------- -------------------------- --------- ---------------------------------- <br /> Disposal Field (Specify Requirements)- --------- -- -------- -------------------------------------------------------------------------------------- ------------------------ <br /> ---------------------------------- -� -- _ � --y. / --------------------- <br /> I <br /> ---- -------------------------------- <br /> (Dra existing and required addition on rev se 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 mpensation la .s of California." <br /> Signed----------------------- ------------ ---- ------ - ------ Owner <br /> BY -- Title--- ( @.XGA-------_----_- ------------ <br /> (If other than owner) 1 <br /> FOR bEPARTMEN7 USE ONLY <br /> APPLICATION ACCEPTED BY------ -- -.- ... ----- -- ------- --------------- ------DATE.-I-5- ---- ;*------------- <br /> DIVISIONOF LAND NUMBER------- ------ -------------------- --- ----------------------------- ------------------------DATE------------ ---- ----- ---------------------- <br /> ADDITIONALCOMMENTS------- -- --------------------------------------------------------------------- -------------------------------- ---------------------------------------- <br /> ---------- <br /> --------------------------------I-------------------------------------------- -------------------------------------------------------------------- -----------I------------------------ ------------------------- <br /> -------- -------------------------------------- - <br /> -- <br /> Final Inspection by:------------ <br /> Date <br /> EH 13 24 SAN JOAQUIN LOCAL HEXLTH DISTRICT res 21677 REV. 776 3M <br />