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FOR OFFICE USE: FOR OFFICE USE: <br /> -s APPLICATION`FOR SANITATION PERMIT <br /> ............... -------- ....... <br /> (Complete in Triplicate) Permit No� -_,/-' .�. <br /> Date Issued... 7..'.?.� <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/LOCATION.. t�._..6�:...:l�'f���7���' <br /> _-------------CENSUS TRACT_........____ --- <br /> Owner's Name._. . . _ ._ (g � ..Phone.-- -------- --- <br /> `+?' <br /> Address------ - ............. -- --------- ---------- - -- -.---- City..........------------------------------------Zip--...__.-.._.. - -- <br /> _ <br /> Contractor's Name__ _.�r7�, License 0 <br /> -� �1 - Phone-- y <br /> a7�? OL9 f- - <br /> Installation will serve: ResidenceX Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> M tel ❑ Other <br /> Number of living units:-._ ._._-..__Number of bedrooms------(r% Garbage Grinder............lot Size-----19,6 <br /> Water Supply: Public System and name._.... ..........._--------------------- --__-.Private ( <br /> ^a <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe EJ 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size X/0-............. Liquid Depth......__._._-__. <br /> Capacity-1- .__n--.. Material. -----No. Compartments..._. <br /> Distance to nearest: Well_...._../._Q_(/...._. ..__.-__...Foundation-.-__110--.. _.__. Prop. Line_/0__,0------.-_.a <br /> LEACHING LINE [ ] No. of Lines . _19-1-----------------.Length of each line.._..-.O_. ------------Total Length .. f--d----..____..__........__..- <br /> 'D' Box-./ Type Filter Material_(I. Depth Filter Material.__/_r----- - ---_---•_------------- ------------ --------- <br /> Distance to nearest: Well-------.._._.._....�_p_ Foundation-___-------.-_-__--------Property Line_.._._._-_.....__........_------ <br /> SEEPAGE PIT [ ] Depth. Diameter...-_ Number___.__:6_ __ Rock Filled Yes No ❑ <br /> -r , -.- (T� - <br /> Water Table Depth------------ ........... ----------- ------...Rock Size..._`..../ --------------------------- <br /> Distance to nearest: Well._.-.......__�_3� 4. ).._. ..-__.Foundation.--------- .. -. .....Prop. Line.._.....-.__.._-..._.-._. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------- ...............Date._.---.:_. ...------) <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 ompensation laws of California." <br /> Signed------ ----- - ---- ------- -----Owner <br /> By..------. - _ .. Title. - - - <br /> (I other than owner) <br /> f0ft DEPART ENT USE ON <br /> APPLICATION ACCEPTED BY-- DATE . .-_- . . . - - - ----_. . ------- <br /> - .. <br /> DIVISION OF LAND NUMBER..- -------- ----- -------- -- ......-_.DATE----- - <br /> ADDITIONAL COMMENTS__.-__---__...__. ----- - -- <br /> ------ ----- ---- - ----------- --- --- ----------------------------- ------- --------- 1.__.------------------- - -------- <br /> --- - <br /> ----f---------------------------------- ------------ -- - - ---- <br /> y-- � -- - - �,� � -- Date - <br /> Final Inspection by:.� -� - - - - -��--- - --i`---�� ---------- - - - ---------------•------- - --- -- <br /> EH 13 24 SkN JOAQUIN LOCAL HEALTH DISTRICT FaS 21677 REV. 7/76 3M <br />