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1 <br /> FOR OFFICE USE; / FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT <br /> 7�-• d2i1F <br /> ---- - ------- - -- - Permit No.--� ------ . ..----- <br /> (Complete in Triplicate) - <br /> -------------------------- . - d <br /> Dote Issued.-._..� �.� <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 describedt <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 Name.... .._"W0I-U..... --.....------ - Phone <br /> � d Zi Cit , �.. . <br /> Address-... / ------- ......... .. y—. P <br /> Contractor's Name..-..�iJs."+ ��.. h- i? �rSP�r License # d. .Pd_11........Phone <br /> Installation will serve; Residence ❑ Apartment House ❑ Commerciale Trailer Court ❑ l .7 <br /> Motel ❑ Other. ................. ...... <br /> Number of living units:-------------.-.Number of bedrooms............Garbage Grinder------------Lot Size----,��... -------:...:........ ..... .. <br /> Water Supply. Public System and name.- - ----------------- - <br /> - ------.- . --.-----.---_------ ------- -- ----- -----------Private <br /> ----- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ l <br /> Hardpan ❑ Adobelm 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 <br /> [/'J SEPTIC TANK PQ Size -------------------------------- --------------- liquid Depth.------------- ....--- 40 <br /> Capacity_/.;)-0:0__ Type-/?g..(,/s.J`:....Material.&,ACGel.��--..:No. Compartments-------- --- <br /> LEACHIN Distance to nearest: Well.... .01�1..._......... <br /> Foundation--•---AQ Prop. Line- -,.1270. --. ----- <br /> G LINE De) No. of Lines _.... .`---- ------ <br /> Length of each line...-�jJl�._-_......:... Total Length .. .....-.. <br /> 'D' Box----........Type Filter Material........ .... .... Depth Filter Material...............-------- ------------------------------.----.---- <br /> Distanceto nearest: Well.............................Foundation.....................-------Property Line----------------- -------.---..-.--. <br /> SEEPAGE PIT Depth....� -- // Rock Filled Yesx No <br /> Drameter_-. Number J ❑ <br /> Water Table Depth---------- .Rock Size-------------------- ----------------- ------ -- <br /> Distance to nearest: Well---- - . ---------.-Foundation.... ..............Prop. Line..__/ -------- <br /> REPAIR/ADDITION <br /> -._. _REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- -------.......Date.......... <br /> .......------ --...........-:._.._.:) <br /> Septic Tank k {Specify Requirements)--....:.-.......---•------------------------ - --------------------------------------- - - ----..,..-------- --------------- <br /> Disposal <br /> ---'---------Disposal Field (Specify Requirements) ----------- --------------...............................................-- - ----- --- -------------------- - ............... <br /> -------------------------- ............ --------------- ----------------- ----- --........ -------- <br /> ------------------------ ....-- . -------- -----. - ----------- <br /> (Drow existing and required addition on reverse sidel <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, Horne 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 sub ect to ma C mp scitio ws of California." <br /> Signed.-.-. _ _-- f <br /> ////fa��/� ...Owner <br /> By... Title....- .... - f <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...- ...--- --- ......DATE .'�`�. = 1.......:.. ..... ... <br /> DIVISION OF LAND NUMBER........ ...... ............ .. ...... -------------- ----------- - -- ....DATE....- ......----.....---- <br /> ADDITIONAL COMMENTS. .................----- ---- <br /> ---------------- ---------- ------------------ ......_......--- ..--------------- ------------------ - -- ---------- _...... <br /> ...................--------:............ .......... . .................•-------...-...-........... ---....... ------..... ................ ..... -- ----------- ----- <br /> --------------------- -------•- --- <br /> ..... ... ------ -----•---•-- -------------- --- -----!- <br /> Final Inspecf,on by:------------------------- - ---- --------------------------- ----------------- - Date. AZ- _28............. _ ' ..... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALT TRICT F&S 21677 REV. 7/76 3M q'� <br />