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FOR OFFICE USE: \ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.__- _ -__ .______. <br /> Date Issued--- <br /> ------------------------ -----------­------------ <br /> ssued___..-..--..________________.______-_.-.___.______ ____ 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/LOCATI N____- ;0 7 _ C /� <br /> -------- - -- ------- --ems--------------------- ------ - ------- ----CENSUS TRACT__ <br /> Owner's Name �e1.�<+0. fC - --------- ----------- ------------------------Phone----- vS -S/.2Z�3 <br /> /� -}� <br /> Address_--_---�_7�� _ /1�l - �-l' <br /> - _ -----City-------I— --------------- Zip 93_ �O <br /> ,((�� -- - ---------------- - <br /> Contractor's Name__,&ffC'--- ..__., 6-1_-."PC----------------------------------License #._v'v5"7 l_____Phone_- x_3 33 <br /> Installation will serve: Residence k;/Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------------- -- / <br /> Number of living units:____[________Number of bedrooms_.______----Garbage Grinder------------Lot Size_____1`/_Q.cc-i_______________________ <br /> ------a <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 <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-----------------------------------------------------------Liquid Depth-____________--__-__._-- <br /> Capacity --------- Type----------------------Material------------ ---No. Compartments--------- ------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line_____. .___--- <br /> LEACHING LINE [ ] No. of Lines---------------------------- of each line-------...__..-----------------Total Length------- -_______________-----_-_.___._ <br /> 'D' Box___________Type Filter Material--------------------Depth Filter Material__-__---._____--._____ -____________- <br /> Distance to nearest: Well----------------------------Foundation________'___________________Property Line________________.__.--__________--. <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number____--._--____s------------ Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth--------------------------------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Well_------------------------------- -----------Foundation-----.________ ---------- Line-__________._________._____-- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_____=:-_-_______________________.-.._-_._-.-.Date________________________.___-_________--.) <br /> Septic Tank (Specify Requirements)--------- -------------------- -------------- -------- - - -------------- --------- <br /> Disposal Field(Specify Requirements) 0 --------0 -------- ----------------------- � lC'���------- <br /> - /600�_00-- - = /a- - ---- - ---- ------��.. .�-------- -- ------------------ <br /> --------------4�.�-- ---------{ ---------------------- -- -- <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 Work n's Compensation laws of California." <br /> Signed----- -- --- ------ ---- ----- --------------------------------------------------Owner <br /> By------- -- --- - ,_` - - ----------------- -------Title------e&Jc2. <br /> (If other than owner) <br /> FOR DEPARMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ "----- --- --------------------------------------------------DATE. '7^ <br /> DIVISION OF LAND NUMBER-_----------- ------------------------------- -- --- ---------------------------------- -----------.DATE--------------------------------�------- <br /> ADDITIONALCOMMENTS----------------------- --------- ------ ------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- <br /> ----------------- --- ---------------------- ----------------------------------------------------------------------------------------------- ----------------------------------------- <br /> ---------------------------------- --------- q <br /> Final Inspection by Date 1 <br /> Ex 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />