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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------- ---------- <br /> (Complete in Triplicate) Permit No ................. <br /> .. <br /> Date Issued._7_--- <br /> ............ . This Permit Expires 1 Year From Bate 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. 54.9 and existing Rules and Regulations: <br /> �� CENSUS TRACT..---_-.. <br /> JOB ADDR y <br /> ESS/LOCATION.---......j.�� .....I�,��S..13.--�- -- - --- --------------- -- •- ... ------.........: <br /> Owner's Name---- ------.... ti -----------�Y�:� �:/G_............ .................... -- :-- ---• <br /> Address-------- ---------- --------------- ---.:_..: ----Ci A eFitie/1 G�$. >t�.....Zi ------------- -------- <br /> Cantractar's Name...... i -v GCS--� <br /> 1, - -----------License #- _ ...Phone__ •�' ._1�� .ST? <br /> Installation will serve: Residence [d}—­Apartrment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.........------------......................... <br /> Number of living units:.. .....'__Number of bedrooms._-___,Garboge 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 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 beplaced on reverse side:l <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ ] ,n Size ... � .X�--------------------------Liquid Depth._�0- �......_-_f - <br /> Capacity 6- ; <br /> -----.TYP ff{� ?C- �Material---------------`-" No, Compartments.----... ... -----.---- <br /> Distance to nearest: Well.:... •_ d__.r _____ _____Foundations ( _ . .....Pro Line_-- �rT <br /> �� p. .....T_._... <br /> LEACHING LINE .. <br /> ( ] No, of Lines... ..............Length of eaeh lina._..��.._....___._.._.Total Length .. .- .C,t._T.------.--.-� <br /> 'D' Box--l..._. Type Filter Material.iDepth Filter, Material...__..�.�_-� <br /> Distance to nearest: Well__16...... ...... '`:Foundation.oZ4)--/77------Property Line ......... <br /> SEEPAGE PIT ( ] Depth.............. .Diameter----_-----_-----Number------------- -------------------- Rack Filled Yes ❑ No ❑ <br /> Water Table Depth--------------------- ------- ......... -----------------Rock Size.- ......... - <br /> Distance to nearest:-Well..................... --------- .............Founda'tion:...._..._.._.......- -- Prop, Line-----------.-_--_-------_- <br /> REPAIR/ADDITION (Prev. Sanitation .Permit#-------------- ------- --~-----------Date .-------..-...------...... ] <br /> Septic Tank (Specify Requirements)------ -------------------- ................................. ----------- ------- ---.......... .-------------------------- --------------Disposal Field {Specify Requirements)........:............: ..... . <br /> .................. ---- .............. <br /> ------------- - 'f. <br /> --------------- ------ ................... .._...- ------ <br /> i ] <br /> . (Draw existing and required addition on reverse side] 1 <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—ofthe 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 became subject to orkman's Coriipensatior� laws of California." <br /> Signed ....... -------------- --- --- <br /> By----- ..... <br /> --By-----=•--•- ------ .......- ...... .......Title---------- --------- --- <br /> r (if other than owner) , <br /> OR PARTM T IffiE ONLY <br /> APPLICATION ACCEPTED BY. ---... M..'""^"t--'-- --.._... .............DATE .-..--. --- -a. <br /> ..... _ <br /> - - ------ ---------------- <br /> QiVISION OF LAND NUMBER `.: :: .�.. ... - ._..` f - -------------'------ ----..:_.DATE::._...... i.----== <br /> ADDITIONAL COMMENTS...I ...�. -""��--�'-�----- �. .. ��-= 44---------------- ------------------- ........... <br /> •- ------------------------------ ------------------------------- ----- ............. •----- <br /> ----------- ------:---------------_-- - p�. <br /> Final Inspection by:._-.. -- . ------------------------------- ----- ------ -----• -----------------------._Date --------� ' ^�i <br /> EN 13 24 f T REV. 7/76 3M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br />