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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> '= �j (Complete in Triplicate) Permit No. -- <br /> ........ .1 --- `--° <br /> --------- - - - - - - -- -- This Permit Expires 1 Year From Dote Issued 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. 49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI [_ - _Q I- <br /> - -- --- --- -- -- -- -�� �_ T RACT. -- -- <br /> Owner's Name rPhone. <br /> Address �±� � .----- ' ---------- it Zip <br /> Contractor's Name <br /> _ -- <br /> ��--- - - - r ,r/a '„� <br /> _,.��_ ..-.__License #_�--w-�/_'��--Phone... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other____ <br /> Number of living units_______ _Number of b drooms 4 <br /> __..Garbage Grinder-4!9'-Lot Size__/r�C� <br /> Water Supply: Public System and name ____ CE-� --.- __________Private ' <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe HIPMaterial--. _____ .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 [ ]' r ° ' /U ' el <br /> Size . l ----- --- --Liquid Depth �-- <br /> Capacityj.2 766 Type/ -Matwial- o. Compartments ------ — <br /> Distance to nearest: Well---.S--C7 /, _ Foundation Prop. Line___a�� <br /> / ±- ----- - <br /> LEACHING LINE X No. of Lines.--F Length of each line_ 1 ' �• <br /> - - -Total Length -- _.Ur1- <br /> 'D' Box.-g-_ Type Filter Material__/ <br /> r_ ___. Depth''filter Material- - _ <br /> ------- -------- - <br /> Distance to nearest: Wellx� -- -_--_.FoundationProperty Line .._- .- <br /> --------- <br /> SEEPAGE PIT Y Depth�� Diameter �GMr <br /> Number-- - Rock Filled Yes �( No <br /> F- <br /> Water Table Depth---- T --�------ ----------- --- --------- --Rock Size <br /> Distance to nearest: Well_ / <br /> f � - --------Foundation . �d. Prop. LinebS-r --� - <br /> REPAIR/ADDITION {Prev. Sanitation Permit# ate --- <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 Son 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 <br /> SERVICE <br /> ' -- --..Title --- - 0 <br /> (If other than( wrier 671.77. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B <br /> -- - -DATE_ <br /> DIVISION OF LAND NUMBER __ ------ . <br /> ------ <br /> --- -- --- <br /> ADDITIO <br /> NAL COMMENTS_ ------- ___ . - DATE <br /> - - <br /> -- --- ----------J-------- -- - ------ -- ---------- -- - -------- ------ ---- ------- <br /> } - -- _ ----- ------ -------- - --- - -------- - -- - -------- -- <br /> r _ <br /> ��' --- --- -- ------- <br /> ------ ----- - - <br /> ina Inspection by; _4_ -.- ---Date--- --� -'-� y� <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV, 7176 3M <br />