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FOR OFFICE USE: FOR OFFICE USE: I <br /> APPLICATIOM FOR SANITATION PERMIT <br /> 3d Permit No.-7.-_- -- <br /> [Complete in Triplicate] ; <br /> ----------------- ------------ ...... <br /> Date Issued..6 .7--- -...7-f" ; <br /> ......•• --- ....•..-- This Permit Expires I Year From Date Issued <br /> i <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and:iristali the work herein described. <br /> This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATy Q <br /> CENSUS TRACT.................. ............. <br /> Owner's Name... - ...... • ........ ...... . .. -- --=-----•--- -------------- -- . ------Phone...-- ----------------------....Address-- --- - -- ----City-•................ ...........................ZiP--:.................. <br /> Contractor's Name_. License #.... . .._- . Phone--[ = <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ -Trailer Court ❑ <br /> tel ❑ Other,........... .- --------------------------- <br /> Number of living units;.......l-------Number of bedrooms_ .. .....Garbage Grinder............Lot Size--.A0.7. . <br /> L; <br /> Water Supply: Public System and name............ . -- -•-------•----- ---- - --Private ❑ <br /> Character of soil to a depth of 3 feet; Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam [] Clay Loam <br /> Hardpan ❑ 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,) <br /> PACKAGE TREATMENT [. ] SEPTIC TANKSIZE Liquid Depth. ._ <br /> [ ] . <br /> Capacity-/A-+t.t5----TYPe=-1-19............`Material ---- ::No. Compartments---- ------------------- <br /> I _ <br /> Distance to nearest: Well............ ------ <br /> Foundation----- ....Prop. Line.....,b................. <br /> LEACHING LINE [ J No. of Lines .._....-. ..Length of each line.. �7 --- ----------- <br /> �. g ��,.---•--- • --Total Length �C-�u------ - <br /> 'D' Box...t.........Type Filter Material.. .:...Depth Filter Material-, - - ---. .------.--------------------------............ <br /> Distance to nearest: Wei l---< . . ..,__:Foundation_._:------------ ...Property Line------------,_..:------------- <br /> SEEPAGE PET [ ] epth.......... .....Diameter..---.._.-- Number....------- ---------. -- Rock Filled Yes ] No ❑ <br /> Water Table Depth----- ----- ---•--------- -- ----- ----- Rock Size./.. <br /> Distance to nearest: Well-:-----------------------------------------Foundation_,-.:_._-- _-- --.....__Prop, Line..-__.:°---.-.--..----..- <br /> REPAIR/ADDIT16N (Prev. Sanitation Permit#-----------------=--------------- - .-.--...Date..............-.. ------ --.-- -- ---- - -- _) <br /> Septic Tank (Specify Requirements)---- . . ----- --------------=------ - .... . .......... <br /> Disposal Field (Specify Requirements)............... A <br /> ---- -- -----­-------------------- ------- <br /> A <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 Joaq`u'in'tocai Health District. Home owner or licensed agents <br /> signature certifies the following: i <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 Workmbn's Compensation laws of California." <br /> Signed......---.---- -- - ------ -- - - ------------ ---- ------ - ----..._Owner <br /> By .. Title.............. ...•--- ------ .................... ............ . <br /> (If other than owner) <br /> FOR D PARTMENT SE ONLY <br /> APPLICATIQN ACCEPTED BY.........-. <br /> ...............DATE -----��.. 7. -7�.......-- .---..:. <br /> DIVISION OF LAND NUMBER.... ............ ............... ........DATE... -------- ........ ....... <br /> ADDITIONAL COMMENTS............... .... . ... ... ..... <br /> --- -.. ...... <br /> ---------------------------------------- - r y .-.-.... __ <br /> 'Final Inspection by:..... T ...... <br /> ----•--- ............................................ ......._-Date...�P. -�� -�--... <br /> EN 13 2" SAN JOAQUIN LOCAL HEALTH DISTRICT (((((( Fes 21677 REV. 7/76 9M <br />