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1 <br /> FOR OFFICE USE. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....................................... ........-- i <br /> (Complete in Triplicate) Permit No ',�_ - I--- <br /> ...� ...... Date issued � .��. <br /> � , <br /> ••-•••....... .................... ............... This Permit Expires t Year From Date Issued > <br /> Application is hereby made to.the San Joaquin Local Heatt'li District'.for;a �ermit 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; a <br /> JOB ADDRESS/LOCATI r . <br /> L��. ..... :. --- ---- -------------CENSUS TRACT----------------------- ........ <br /> 1 <br /> Owners Name.- ....... ------ =------ -------......--;.....-------......------•--------------....-..Phone..- .... ;= <br /> Address . ...City--• ----------------•------•--....---.--....--Zip--. . .- -_---------- <br /> C - "0 <br /> ontractor's Name..... _ ........ .........License #,,7,CO f. Phone.. :.. /.e.Z,."//' <br /> l <br /> Installation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other............ ................................. <br /> Number of living units:..----.-- .-•---Number of bedrooms------.-_-.-Ga a ep Grinder------------Lot Size_.......:..... ................... ............._ .. _. ¢ <br /> Water Supply: Public System and name-------------------- _ _ �. Private ❑ <br /> --,. <br /> Character of soil to a depth of 3 feet: Sand ❑ ' Sit❑ Clay ❑ Peau]] Sandy Loam Q iClay Loam ❑ <br /> Hardpan ❑ Adobe❑ k 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 reveYrse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public-sewer is'bvailable within 200 feet,) <br /> PACKAGE TREATMENT ----------------Al -� <br /> [ ] SEPTIC TANK ( ] s Size---------- ---- Liquid Depth..---------.------..... <br /> t <br /> Capacity --------.Type --------.............Material----•--- ---No. Compartments.---- fl <br /> Distance to nearest: Well............................................Foundation-------... . ...;._....__.Prop. Line........................ N <br /> I <br /> [ ] No. of Lines.....:.........------'-.....Length of each line----....----------------..... TotalfLength ...,-�- <br /> LEACHING LINE -:--------- ----­----------- <br /> 'D' <br /> ---- --------•-'D' Box........ ...Type Filter Material:- - ___•Depth Filter Material:........ -------. . e _ .. I <br /> Distance to nearest: Welt _J9 c ..._/..Foundation.............:..............Property Line.................................... <br /> 1 <br /> SEEPAGE PIT ( ] Depth...........__.Diameter--------------------Number....-------------------....:.... Rock Fillets Yes ❑ No'Sa1 <br /> Water Table Depth.---- '--=---...._- ....}. Rock Size. -------- -------------------- T' <br /> . t `t � t <br /> Distance to nearest: Well----------_. '___'`_. _ 'n" �"^'' ' ' <br /> ----._-..._.:._Foundation,.-------------•.•-._.-.•....Prop. Line-- - ---- -------�---- -- <br /> REPAIR/ADDITION (Prev, Sanitation Permit#----------------------------_-.------.- -.--- Date.-----:-:r.4s --`...- ,-�°'=--y- --) <br /> Septic Tank(Specify'Requirements] .= ..:== y vT' - ------------------------ -- =------------------------ <br /> Disposal Field (Specify Requirement ----- ------ = ------- ` - yi' r _.............. <br /> -------------------------- --------------------------- E f� <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: 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 Workman's Compensation laws of California." , <br /> Signed............ Owner <br /> --•--- ------------------------..... <br /> By................ -- -- ----- --�-- -. �. .0 --•• - - - ^--•-- - -- -----Title - ----------•--•---.... E <br /> f other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ -- - - w*..................... .DATE ...'�--,�,��...----- -- ........... <br /> DIVISIONOF LAND NUMBER ------ ------------------------------------- ------------------- .......................... DATE--- ............. . <br /> ADDITIONALCOMMENTS............... ....................................... ------------------------- --------------------------------------------*.................... ............ . <br /> -------------- ----- ............ .......................................................... - ------------------ --------------..-------- -------------- <br /> ---------------•----•- ••- <br /> Final Inspection b s ---------- -- ----------Date ------�a ....._ ........... <br /> Ex 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FLS 21677 REV. 7/76 <br />