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F R OFFICE USE: �_; . FOR OFFICE USE: <br /> 3 �a//�- APPLICATICi`N 6l SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> ................ <br /> ------------------ <br /> Date Issued--- <br /> .............I............. 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 l.. .. Lj. <br /> . .. ----_-------------......CENSUS TRACT-----........ <br /> Owner's Name .- � ` � -------------------- - Phone <br /> Address--.-.-..-----. ���'' : <br /> - -- - - --------- -- - - .. -- CitY--------- - - --- -- - - ... _Zip------------------ ._.. <br /> Contractor's Name.. __ License #- Phone.. ... <br /> Installation will serve: esidence EJApartment House EJ Commercial Trailer Court F] <br /> Motel ❑ Other----------------------------- . <br /> Number of living units;........ -------Number of bedrooms.------- Garbage Grinder._..----....Lot Size/,�_ _ �- ?. .. ............ _._ .. <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,) 19 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size ---LO` 0:.A.161............ ------------.--Liquid Depth..................... <br /> Capacity. Type---A--....._.-...Material- ..._: No. Compartments"_._ Z� <br /> Distance to nearest: Well.......... . ----------- ......Foundation.....1.4� -........ ...Prop. Line. .............-------ZIA <br /> LEACHING LINE No. of Lines ." ---- Length of ea h line.-.... .. - _...._-Total length -. 1--Gt-�'- <br /> 1 <br /> 'D' Box._.. .. . Type Filter Material-... .. . .Depth Filter Material.-_/..F7...... ----............... ........__._..-... .. <br /> Distance to nearest: Well---- 6>.......-------Foundation.-_ . ................Property Line-... ------......__-___.� <br /> SEEPAGE PIT [ ] Depth__------ Diameter--------------------Number-._.----------------_---------- Rock Filled Yes, No <br /> Water Table Depth...................... Rock Size....-./._ <br /> ------ ------- ----- / ------ <br /> Distance to nearest: Well-_..._.... ._. ...................Foundation........-------- ..-------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',4 Compensation laws of California." <br /> Signed ,f_ Owner <br /> / <br /> 4 <br /> By............ L! G' A'"--• ------------------------- ------Title.. ------------- -...----•- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ evy... <br /> ---- <br /> Y .--- --- --------- ----------------- ------- ......--- .DATE- ._...3 1rQ <br /> DIVISION OF LAND NUMBER.............__-...- ....._.......DATE------.------ ------ ---------- <br /> ADDITIONAL COMMENTS------------- .. ..____ • . ----- ...-.-.. ..--- . <br /> ....................... ----- ---------- -- .._...... ..._...----.... -- ------ ----- -- ------ .... --•-------•------ - ................... .......... - ----............... <br /> ----------- ------ -------------------- _ --- ---- --------- <br /> --------------------------- ---- .- -----------... <br /> ............................................... <br /> ---------•...........................-- . ---------- - . . ---------- ---------- - --- ...-- --- <br /> Final Inspection by------ --- ........... --------- --------------•--- ----------------._........Date.-..._ .�d . ..............- <br /> EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M <br />