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FOR OFFICE USE: C / FOR OFFICE USE <br /> � ; <br /> '{"// APPLICATION FOR SANITATION PERMIT <br /> - •�o�' -- (Complete in Triplicate) <br /> Permit No.��_n_"A__ r <br /> ..----�-•---�--•.........................�----.....-- Date Issued/.f,1.:a.Yar.7-g <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 existin Rules and Regulations: <br /> JOB ADDRESS/LOCATI ... .. `5 --' r- CENSUS TRACT.. <br /> Owner's Name.. r _ .: r....... Phone. <br /> J ' <br /> Address................... . �, ! Y Zip- = <br /> Contractors Name__- - - � . <br /> !-�- --------- ..� License # / .. ��-Phone. �,J'=� G/� <br /> ................... . ....... <br /> Installation will serve: Residence r Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- ...... --------------------:-- --Number of living units:... ---------Number of bedrooms>-?_....Garbage Grinder- ...Lot Size__, -... _ <br /> y --------------------- - ------ ---------------- _.---- .-- ------ ....--- .....--.--.--....`...... ; <br /> Water Supply: Public System and name_-__ private ❑ <br /> Character of soil to a depth of 3 feet: Sand Y YP W <br /> p _ MaterialWO.lf'❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loom ❑ <br /> Hardpan ❑ Adobe F FIII - es, 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 eq Size.... `� /L4l�/ <br /> ' <br /> ------- -Liquid Depth .. ---- ---- i <br /> acit <br /> p Y - Type Compartments_Ca ) IrG_ aterial o. artments .._. �................ <br /> ....�' <br /> t <br /> ' tante to nearest: Well.:--.-, .�------------------------Foundation....... Prop. Line_. .... --.--.....--.-- , <br /> LEACHING LINE 0 dLength .. ! Q <br /> [ No. of Lines.;_.-. Length of each line...�� Total .,/__2,-6................ ... <br /> D' Boxytc <br /> rType Filter Material./? (✓ Depth Filter rial.. . ._�---------------------J...-....----..----..,�` <br /> F Distance nearest: Well.... F ......Foundation_.........._.........Property Line......' ........................ <br /> SEEPAGE PIT <br /> [ De th. t ... _._ ' Nu-mber... ..2--------------------- �� Rock <br /> Filled Yes <br /> j� <br /> � o <br /> Water Table Depth -----------------Rock Size-.... .-------- <br /> Distance to nearest: Well.-.------ .U---------------------------Foundation . ..............Prop. Line_ ;_/....... ....-❑.. <br /> REPAIR/ADDITION . <br /> ; <br /> (Prev. Sanitation Permit#--................:........ ........._.__ -....._....Date.------......-...------------------ ----_-----) <br /> Septic Tank (Specify Requirements)_.-. ---------------------------------- ----------------------- �: <br /> Disposal Field (Specify Requirements):.....!............... ...... ----------------------. <br /> :.... ------ <br /> ------------------------------ - .._-- -----------•-----•---..-....-..---- .......... ---- ....... <br /> i. <br /> - i <br /> --------------- --- ........... -------- ----- ------------- -----------------------�- --------- ----------..-------- - <br /> --- - - ------- <br /> _ (Draw existing and required addition on reverse.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 Compensation`laws- of California.” <br /> Signed.. ----------------------- <br /> .Owner <br /> By.. <br /> ..... ..........Title.. ---- <br /> (If other than owner) <br /> _;R DE RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-._ -• DATE�O.. ...�G - ' <br /> DIVISION OF LAND NUMBER......._..�..1------------------------------ ..............DATE-------................. <br /> ADDITIONALCOMMENTS.........------..... ......... --------------------------------- ..-......... ............ <br /> --- --------- - ----------- --- - ....... ------------------•-------.....-..-----------------.._..-----•-----•--.-.---------•-- -------------------•--- ...: ....--- <br /> -------------- - ^� <br /> Final Ins ectlan b Date_.-� . ............... ----- <br /> EH .. ..... -- ------------------------- --- ----. / <br /> EH is 2a SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7/76 3M <br /> I <br />