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FOR OFFICE USE: FOR OFFICE USE: <br /> �� APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- �I\' Permit No---3-q- 5-a-y- <br /> ----------------------------- (Complete in Triplicate) <br /> Date Issued-_6- ..--.-.---- <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/LOCATIO .-/��_ ------- ----------------------------------------CENSUS TRACT----- ------------------------- <br /> Owner's Name---- --- -- ----- --------------------------------- ----- <br /> ---- -------------Phone------------------------------------- <br /> Ci ---- --------------- --zip------------------------------ <br /> - <br /> ------- 3- -- -- ---- ------ - # 222 <br /> Contractor's Name -//-----(F---License #-- - --- ------------Phone---------------------------------- <br /> Installation will serve: Residence�1/ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------------------- -- ------ <br /> Number of living units:------ -.._____Number of bedrooms---3-___Garbage Grinder------.-----Lot Size <br /> WaterWater <br /> Supply: Public System and name------------------------------------------------ --------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam e 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 see age pit permitted if public sewer is available within 200 feet,) y <br /> QQ � <br /> PACKAGE TREATMENT [ ] SEPTIC' <br /> [ <br /> Size- � _I- _ - -------------------Liquid Depth-__ ---------------- <br /> Material._--_ ' No. Compartments_____. "`--------------------- <br /> Capacity-- �-----------Type- "` � --- � <br /> ( : _ <br /> Distance to nearest: Well-------------- �-------------------------Foundation-------10___...........Prop. Line_--1-----_____----------- <br /> LEACHING LINE [P1 No. of Lines_.___-----------------Length of each line..-__ 0----------------.Tota Length ____x_211.------------------------ <br /> 'D' Box----/---.-.Type Filter Material----,5 I------Depth Filter Material-------- -4---------------------------e---------------- <br /> .- <br /> Distance to nearest: WeIL.___.-_S v___---------Foundation_«______a_Q--- -----------Property Line.____`--------- --------- <br /> t -3------------ Rock Filled Yes No E]Depth-----IeQ------Dierrtet'er ±�--/Number- = - <br /> Water Table Depth---------------- ?---------------------------- _--Rock Size----1 .�-X- - , / <br /> Distance to nearest: Well------------ <br /> _"�o--------------------Foundation-____1_L�--------------Prop. Line_._-_�____--- _.------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#___-__---------------- Die ----------------------------------- <br /> Septic Tank (Specify Requirements)---------- -------------------------------------- --------------------------------------- _\ <br /> Disposal Field(Specify Requirements)---------------------- --------------- ----------- <br /> --------------------------------------=----------------------------------------------------------------- <br /> ---------------- - <br /> -- - - ------------------------------------------------------------------------------------------------------------------------------------ <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: <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 /> By------------------------------------------------------------ - Title--- �L��_ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY '-___ - DATE._ __ ____ _-- --- ------------------------ <br /> --- <br /> --------- -- --------- <br /> -- ------ -- ------- ---------- ----- ---- -------- -------- <br /> -------- ----------- <br /> DIVISION OF LAND NUMBER---------...----.-._-- --___-____..DATE..__.__ <br /> ADDITIONAL COMMENTS-------------------------------------------------------------------------------- ---------- <br /> --------------- ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- -- <br /> -------------------------------- <br /> Final Inspection bDate. ----------------------------------------- <br /> ----p y:--------- <br /> -------------------------------------------- <br /> EH 13 24 SAN JOA01JIN LOCAL HEALTH DISTRICT Fas seen eEv. ��76 3nn <br />