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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> V' "�!1 . <br /> ........... _ <br /> (Complete in Triplicate) Permit NoJ� <br /> 4_� <br /> ( Date Issued.-.:.....::.••...-•••••.............•--.. l 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....i..v ./..✓ Qe!'`^..........................CENSUS TRACT....._ .d. <br /> Owner's Name _._.�.I Phone.'-- <br /> - -- -_. <br /> Address-- ----- - / - ....city..........................-•------ -----------ZiP--.............--...... - <br /> 41 <br /> Contractor's Name_..... ... ..__ ( .... :.__ . I... ................License #. �- 1, --- -Phone. le- �� <br /> Installation will serve: tt esidenceg Apartment House Commercial Trailer Court <br /> otel ❑ Other---- --------.. ... ..... ......... <br /> Number of living units:-----..'-------Number of bedrooms_..3....Garbage Grinder............Lot Size..... . ._ - _.__. <br /> Water Supply: Public System and name.. ..... - -- --------------- _..... ............ <br /> ..... Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy LoamClay Loam EJHardpan E] 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 . .x_: �A.. ��.....................Liquid Depth.... <br /> " �. .. No. Compartments----Al-------------- ......_ .Type. Merial. -. .__ at ... <br /> Distance to nearest: Well .... ... ..........._-__-----Foundation..�_� Prop. Line....f7'..C�. ^' <br /> LEACHING LINE [ ) No. of Lines__..................Length of each line.....42 ..-------Total Length .. /.._ � <br /> it <br /> 'D' Bo*�/ Type Filter Material._..._ Depth Filter Material.-17......................----------....._..._......... � <br /> leelspp'tar <br /> .Z t r1arest: Well--••-•--•---_-----------_Foundation.--_--•-------------__Property Line..--•-_------_ ...... <br /> [ ]$.x .__------ -- .Diameter............... ....Number_.__. ----------- Rock Filled Yes No ❑ <br /> Water Table Depth-------------------------- ----------------•---.Rock Size---I- . . ................................ <br /> Distance to nearest: Well.. .................._-------- ..........Foundation........._................Prop. Line...----- -..-. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.....----------------------------------------------Date---------------------------------------------- <br /> Septic <br /> -------:_-.- ----._._-------------Septic Tank (Specify Requirements). -- .. -------•-- .............................. --------- ----- ......................... ---------_---- <br /> Disposal <br /> --- ---_----Disposal Field (Specify Requirements)...................... . -------- ----•- <br /> -----•.............•-------- ..--•----- ---- -- -----....................---------------- ... ....................................... ------. . --...:.........•._•----- ..... --- ----•------- <br /> ---•-••-•---•----- ------•- --------------- --------- -------------•---_-- -------- --- ---------------------------------------•...........___------ ------•----------------- --------------... <br /> (Draw existing and required addition on reverse side) <br /> 1 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._. . . •----- -- --- - ----- - ------------- - --------.--Owner <br /> ----------------Title----- -------------- --- <br /> If other th n owner) <br /> FO DEP RT ENT USE ONLY <br /> 09 <br /> APPLICATION ACCEPTED BY. ., . ".. ..... ............. -----....DATE ' <br /> DIVISION OF LAND NUMBE -------- ----- ......• . _. _: DATE.------ --_------- ------- ------ - <br /> ADDITIONAL COMMENTS.- - / J� - . • _14 * - <br /> ----------------- -- -- -- -----.... •--• ..... --------------------.................................. ................................. -------------------------------. ---- ------ .. ... --•- <br /> --••-•-•-- ----------------- ...... ------------.... ----..... ------ ---------------•--•............-•---------•----------.....---•-•---- ................................................ <br /> .................................... <br /> -p� ---------/ . - ------ <br /> Final Inspection by:..... .-!\\�. - --------------••......._T---••----- ............-....................................Date...b_`a'��--- ---• ..... _..... <br /> EH 13 24 AN JOA UIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> S Q <br />