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FOR OFFICE USE: FOR OFFICE USE: <br /> f- '�'APPLICATION FOR SANITATION PERMIT <br /> ............ <br /> ► (Complete in Triplicate) Permit No..7 �... --:- <br /> Date IssuedA9.- .#�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-----•_-- .-�.�.�.�- -•-G��."�'�'��`` . -- ---------- ------CENSUS TRACT---•--- _-.--- <br /> Owner's Name.... ...t^. C t.GT - . --- .... Phone - ................... <br /> Address...... � _ - �(� - - Cit --Zip <br /> City ... - -- <br /> Contractor's Name-------- <br /> License #.. .. - .Phone---f ��- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- - ---- -------- -----_---- <br /> Number <br /> -•---Number of living units:.........-....Number of bedrooms...3-...Garbage Grinder------.....lot -- <br /> Water Supply: Public System and name.. ---------- ----------___------_...----- ------------- --PrivateA <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 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 ---/40------------------------Liquid Depth...: .......... <br /> Capacity. Type-- ----- ------Material.. -----..._No. Compartments---.. ......... <br /> Distance to nearest: Well........lb_r-. -_..................Foundation.....1.40. ......... . Prop. Line........a}------ .-----• <br /> LEACHING LINE [ ] No. of Lines __..� -------------Length of each line........ .. -Total Length __/-./.v----_------_--------- <br /> � <br /> D' Box---/._._.Type Filter Material-----/_ / .__ Depth Filter Material.-_---.r?---------------••-•--- •---------.--•••- <br /> Distance to nearest: Well-----4_g'..d----------Foundation.--.... ........Property Line... '...1k-------------------------- <br /> SEEPAGE PIT [ ) Depth..-1- -Diameter....�°�3----...Number---i�--------------------- Rock Filled Yes j,�] No❑ <br /> Water Table Depth------_------`---- --------- ----- ----------Rock Size------i...� .............................. "� <br /> Distance to nearest: Well.. .._.f ---------------------Foundation/-„e-----`--- -----...Prop. Line_.,...................... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................................. Date....................-_-----.-----..----------) <br /> Septic Tank (Specify Requirements).----- -- -------------------------------------- ----- ------•-. <br /> Disposal Field (Specify Requirements)... .....-_------- ------------- •-•---- <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..... ..... - ==_r .. -- ----- ---- --- ---- ------------Owner <br /> By....-• ---- 1-'�---- -- <br /> (If <br /> £ ? Title - - _. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY Af <br /> APPLICATION ACCEPTED BY..------ - - •-•----- -•---------------------DATE - '... .. y. <br /> DIVISION OF LAND NUMBER. -----.DATE.- --------------------------- ------ <br /> ADDITIONALCOMMENTS-- ----_-_------- ---------- --------------------------•------------------- .....----- --...._...----- - <br /> ----------------------------------. <br /> ....---•----------------------------------------------- ------- ...................... ------------...------------- -------------•-----...... <br /> -- <br /> Final Inspection by;-- --------- ----------- -- ------ ------ Date -EH 13 24 SAN JOAQUIN LOCAL HEALTH D RICT F85 21677 REV. 7/76 3M <br />