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-� FOR OFFICE USE: FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT , <br /> 9 """ k_ (Complete in Triplicate) Permit <br /> Date Issued./fJ._1�rr.. <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/LOC ION l - S ......!.� ! �'�J --------------CENSUS TRACT,....------------_--- ...... <br /> Owner's Name._.. /- Phone... _�1�.-f� ........ <br /> Address. { ,��5. ,¢r _.._ ;.. City- Zip <br /> Contractor's Name...... .................... - - .....License #- 71. . 3.t9..Phane._� <br /> Installation will serve; Residence ❑ Apartment House ❑ C mmercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.....15-_ . .-- --- --_.- ---- <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 Loam 0 Clay Loam ❑ <br /> Hardpan Adobe ❑ Fill Material.. .... ....If yes, type............................... . <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTAL;ATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ----------- - --------------------------------------- ----Liquid Depth (" <br /> Capacity...... ..............Type............. . .-. mMate-rial--------------------- -...No. Compartments.}----•-------- J <br /> Distance to nearest: Well................... .. ... .. ........Foundation.-•---.... . .............Prop. Line------_........... <br /> .- -.. <br /> LEACHING LINE [ ] No. of Lines .. ...................Length of each line ------.------------- ........Total Length .. ............... <br /> 'D' Box........ ..Type Filter Material-------- ----- ---- Depth Filter Material.. ....____----- ......-----.----------- ------------------. <br /> Distance to nearest: Well."..----•------. -. ------.Foundation----------------------_--.Property Line---------.......----.- <br /> SEEPAGE PIT [ ] Depth---------- -----Diameter---------------.----Number-- --- -------- Rock Filled Yes ❑ N <br /> Water Table Depth---------------------------------- --------------Rock Size.-...,..- ---------._..._----- _--- <br /> Distance to nearest: Well-------------------------------..........--Foundation............... .....Prop. Line-------------------...._..� <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------- .........Date.---------.•--- -...--- <br /> Septic Tank [Specify Requirements)__.-- - .--.-. - <br /> Disposal Field (Specify Requirements)_._...-.. _r___ <br /> f <br /> (Draw existing and required addition on reverse side[ 4 <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 becom [ec to rk, an's rn oensati" laws a�f California." <br /> Signed----- u -- ---f� �------------.... ... Owner t <br /> By---------- ----- ----------- (.+w . ....... ...........Title---- ------- ..........---... ------------ --- <br /> (!f other than owner) <br /> F R 13ARTM T SE O LY <br /> APPLICATION ACCEPTED BY----------- ---------- ------------ --- ............ .DATE .----�a C .... - <br /> DIVISION OF LAND NUMBER....... . ......... : .... ......... DATE. <br /> ADDITIONAL COMMENTS,...... .--.-_• -- <br /> r <br /> ............................... .----- _.._.--------------... --- ............ <br /> ----­------------:.......................... .. ... ... --------- <br /> 6 __...... ----...--- <br /> Fina! Inspection by: 6.'--- `------------ ----------------------- ---- ---- - Date.�CJ. .1�..�o.... ------ <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&S 21677 REV. 7/76 3M.,., <br />