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FOR OFFICE Ute: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------•---•---------- Permit No7$'-�f/-•-- <br /> (Complete in Triplicate) <br /> V Date Issued.!„ -� <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 /> `� �R�r/'t�c G.....CENSUS TRACT................ ------------- <br /> JOB ADDRESS/LOCATION-- -----1=(�_O `�'2..._�:..�.��. :�.....p_.��-- ---�---�---L-... <br /> Owner's Name. ...... Cc_.................... <br /> Phone_� !� <br /> Address--------------- _ _ --------.'Gt..!'�'� / �_......:, .-------------------_ . .. .... City--------------------- ••--•- ...... --ZIP--....... ------...---------- <br /> Contractor's Name......._.............. v� -------- -----......--•....... ...........------- --------License #--..........------.,.-,---.-Phone--_-_--- ------ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-.6umt_t----Rad YH--- ------- <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 V 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 ser is available within 200 feet,) n <br /> � - YP <br /> /^c la T -0?04 Liquid Depth..__174_4..._•--- . ..� <br /> PACKAGE TREATMENT [ j SEPTIC TANK Size 3---- - / IP <br /> Capacity. �Q�. -___T e�I.•-�-•--.&_......Material----C.'o6t.f.l."�C''T�"_.:No. Compartments---------2..........-----•------ <br /> Distance to nearest: Well............ .SQ....................Foundation.......�Q .-�`--. -- Prop. Line__..._5... --..------- <br /> LEACHING LINE (� No. of Lines .------ ...................Length of each line--------._7G---.-------.Total Lengt�f. ..__.7.6?... ....._..... <br /> 'D' Box...../......Type Filter Material�P �� rv�� .Depth Filter Material.........__.r.0 ..--------------- --- ----------------------- <br /> Distance to nearest: Well----....SQ............Foundation--..../.4... ----------Property Line..----..,�.._-F_................ <br /> SEEPAGE PIT [ ] Depth--- ___. ..._Diameter__-----------------Number---_-------- ----------------- Rock Filled Yes ❑ No❑ <br /> Water Table Depth __..... - - <br /> ---------------•---.Rock Size--------.......... ----------._----------_-_ 1 <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, 1 shall not employ any person in such manner as <br /> to become sub[ect Wor an' Compensation laws of California." <br /> Signed... ------... . . ••--- ------ .._...__Owner <br /> By------ --------- ---•---------------- ------- Title.------- -- --------------•-------- ------ -- -------------- <br /> (If <br /> -------- ---(If other than owner) <br /> R JI)EPARTMEWT USE ONLY <br /> APPLICATION ACCEPTED BY........... . .. �^^ DATE ......_//- -- - ------------ - <br /> DIVISION OF LAND NUMBER.-•----.------ --- DATE. - <br /> ADDITIONAL COMMENTS---------- ....------ _.._...._...__._..... <br /> ---------------------------- --- ------­------- ------------------- -------- .................... .................................. ----•--- <br /> ------------------------ ------- -------- -- ----- --- -- ----------------- •------------------•---------------•--•- ----...........-- <br /> --------- ---- - - <br /> Final Inspection b ------------------------- - - - ---- ------ .............. --------..Date. -F <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5,21677 REV. 7/76 3M <br />