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FOR OFFICE USE: FOR OFFICE USE <br /> ----...---•---- ......_ <br /> APPLICATION FOR'SANITATION PERMIT <br /> 79 -�'� <br /> (Complete in Triplicate) Permit No....................... <br /> Date Issued.-._,a '.?. <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 _N/o. 5,4Q9 : <br /> _andd existing Rules and Regulations <br /> JOB ADDRESS/LOCATION.......- ��..._.E� �"`� <br /> ...................................................� 1 �` CENSUS TRACT.................. -- <br /> Owner's Name... �` ���— 34172 <br /> Phone... ......................... <br /> Address Cit �: 't '°`. .. Zi % r��s / <br /> ��-y_fL <br /> Contractor's Name........ icense # .. ?'7d9 ?7 Phone .Q.c. <br /> Installation will serve: Residence ❑ Apartment House C merci l Trailer Court ❑ <br /> Motel ❑ Other-.../LJ_�___�orQ7Q--- � ` � _, <br /> Number of living units:............__Number of bedrooms.... Garbage Grinder............Lot Size.-------- . . . .. ................... <br /> Water Supply: Public System and name. . . .......... --- <br /> --------------- -- - --------- ----------- :---------Private ❑ <br /> Character of soil to a depth of 3 feet; Sand ❑ Silt Q Clay �' Peat ❑ Sandy Loam D Clay Loam El >� <br /> Hardpan Adobe ❑ Fill Mater) . .... ....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 INSTAL;ATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK [ j Size... --------------- Liquid Depth---?!�151* <br /> ------ <br /> .._ <br /> Cop <br /> acityP ---------Type.P?M ate�ral... __..No. Compartments- <br /> ments_.._a-_.._� <br /> /..i..._./...`_ <br /> _._._....... <br /> ...... / Prop. Line-Distance to nearest: Well--- ��- .... fFoundation._:-/-C?.. <br /> LEACHING <br /> LINE ] No. of Lines .. . l <br /> y ` Length of each e -?��� Tot Length - ----- ------ ---- <br /> D' Box...../.....Type Filter Material....._ ......Depth Filter Materia ---------Z-- . ....___..._.._._.... <br /> Distance to ne�rest, Well. -.-- - Foundation_.........................Property Line.._._.....--.---_...- -- ------- <br /> �/' r� <br /> SEEPAGE PIT r Depth--�`�.. .Diameter..-�6 Number....------�------------ Rock Filled Yeses,. No ❑ <br /> D <br /> Water Table Depth-------- 7_1.------ -------------------------Rock Size...------- --------------------------- <br /> Distance <br /> --- ----- -----------Distance to nearest: Well.................. ....'Foundation. .. ......Prop, Line.-___------_----_---.--_ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.....------.----------------_------- ---------------Date-------.-------------..---------------- ------) <br /> Septic Tank (Specify Requirements)...... ................................... -------- ------ --------- .----.----. <br /> Disposal Field (Specify Requirementsl...................... ----- --------------------•----------.-- ---- ---- <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subjectVjcjLWorkmyn's Compensation laws of California." <br /> Signed--- ... _ . ..... --Owner <br /> B -•------ ..-------mm _ _ -. _._.._... Y ......... <br /> Y C�J <br /> Title- <br /> (if other than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ............. .. .................................... DATE _717 ---_---_-- <br /> DIVISION OF LAND NUMBER..-------- ... .................. ------------.------DATE ............. <br /> ADDITIONAL COMMENTS.... --------------------- -------------- -- --- ------- <br /> ------------ -------- -- --------------------------- ........ -------------------•------------------------------ ------ ------- -------------- ------------- -------- ­--- <br /> --------- -- C� <br /> Final lnspecflon by:. - - -----.... �J= <br /> Date.__ <br /> EH 13 24 SAN JOAQUI LOCAL HEALTH DISTRICT' F&s 21677 REV, 7176 3M <br />