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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ?���� <br /> Permit No... .. ............ <br /> (Complete in Triplicate) <br /> -------------- Al ..�---•--............ s e--7 <br /> ' Date Jssued........._. <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 /> ..._CENSUS TRACT."_- -...: <br /> JOB ADDRESS/LOCATION.........I�� . t.'V .-- -...:.*_ 4 <br /> .............: . .....:........................ <br /> ....., ..Phone <br /> Owner's Name....... .:._. ...... . ...... . <br /> -•------ <br /> Address 7�.U: .---• <br /> City--- Zip.. <br /> Contractor's Name­.... � ... ---- ---- License . <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other........ -• --------------------------------- <br /> Number <br /> ----- ------ .-..- <br /> Number of living units:... ....Number of bedrooms..-1..:: . Garbage Grinder..........-Lot Size..-..-5 ---`--- --- ----------- <br /> Water <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 d <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.) 01 <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.Y <br /> Ca acit /AQ°...--..._T a .Material_4i ..................No Compartments . -. . <br /> p y.. . YP - � . <br /> Distance to nearest:Well.-..-.17s'-•-- Foundati n ..._%� Prop Line ....1 5...-.. .__..(D <br /> LEACHING LINE [�j No. of Lines... ... -3. ....... . ....Length of each line...,. (, .......... Total Length _ :-••-f -Q <br /> t ° <br /> 'D' Box. '±'-...Type Filter Material,:��.��......Depth Filter Material..../.r�--• --_•---- <br /> ----Property Line_ ... ._.. <br /> Distance to nearest: Well....Iwo <br /> a.,r�. Foundation.....__......._.. p Y <br /> SEEPAGE PIT 0q] Depth....ZS'7_ .D;iameter-..j7, .7 ........ Num�er.._..3....................... Rock Filled Yes G>feY No❑ <br /> Rock Size.. . ., ' _ <br /> Water Table Depth.:_._../-----_ f� <br /> i <br /> ..Foundation....19 -- :. .......Pro line....�..�....... <br /> Distance to nearest:Well.l,�...:.. ........:. ....:...:.... - - p- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------- .. _........-_...Date................. .............."--•---•------ <br /> Septic <br /> ----Septic Tank (Specify Requirements)----- - .........__............................... . - ........... ----- <br /> Disposal Field (Specify Requirements)... •- .............. ------------.._.......... .. ........ •-•-•.--- -•--•- <br /> ......................-........... -•--............................................ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify tbq!,l 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 JoaquinLocal 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 /> B ��* ,( tafti!dt�? Title. ....: <br /> By <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...- , ............ ..-------------------------------- <br /> DATE �'"// <br /> --- DATE..................... .. .... <br /> DIVISION OF LAND NUMBER............... . ..................................................... ---- - - <br /> .. .... . .. .. . ... . <br /> ADDITIONAL COMMENTS_..................... •..... ......... ......... <br /> ....----- ..... .. <br /> -• ------------ -, -- <br /> JP <br /> Final Inspection b < ---- - ----. Date... <br /> y:.... <br /> F6S 21677 R V. 7/76 3M <br /> EH rs 2, SAN. OAQUIN LOCAL HEALTH DISTRICT <br />