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FOR OFFICE USE: I' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT c <br /> (Complete in Triplicate) Permit o..... .......... <br /> Date Issued._.77 Xf`'7 <br /> ..................... 41Z,.• . . ._... ...... 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/LOC 1044.021-42-4.2 - --- - --- - - ...............- <br /> .---......_-.-- <br /> . ............ ..........CENSUS TRACT. <br /> .. <br /> ...... <br /> Phone.g . .Owner's Name. _ ..._ <br /> Address_... -.CitY _ _Zi <br /> . nse ? Phone../G,.� «.?pG�/Contractor's Name_ --- J - . / <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E]Motel ❑ Other-.__- .._.---------------- ............. <br /> Number of living units:------/_._.Number of bedrooms__.,w. _2_.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 /> Hardpantw 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 [ j Size.-........... ...................:... ----------.-----....Liquid Depth-------........._._..--__� <br /> Capacity..__ _..-------_Type........-------- ----- Material------------------ - ---No. Compartments... ..--.-------- - -� <br /> Distance to nearest: Well............_._._._ ---------___......Foundation.......... . .... .... .. Prop. Line._.._.._...__..__..-.... <br /> LEACHING LINE [ j No. of Lines_...........................Length of each line........ Total Length _ ----- _----- <br /> 'D' Box-----..__-.Type Filter Material........ ......_.Depth Filter Material.. ...................__..--------._.--- -----. <br /> Distance to nearest: Well----.---------------------- Foundation.___.....__-_--___----- -Property Line......------ ----------- _......... <br /> SEEPAGE PIT [ ] Depth._......_... .Diameter........ -..--Number--. Rock Filled Yes ❑ No ❑ <br /> Water Table Depth.----•------------------- . -- . --- ---- --........Rock Size-----------__....................... ------ <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) '7 .......... 7i - - --• ----• <br /> 7` <br /> f <br /> ....... ----- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 /> "1 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 becom s jet to r an s Aompensation laws of California. <br /> Signed.... , , --------.Owner <br /> By.. - •!� C. - Title - - <br /> (If other tPa_ <br /> han owner) <br /> . R DAPARTMEt4T USE ONLY <br /> APPLICATION ACCEPTED BY-------- DATE ....... .&-..79...... . <br /> DIVISION OF LAND NUMBER.----------- - ---- ---_-------_111� _------- --...--.-DATE...... ---- --------.. <br /> ADDITIONAL COMMENTS__............- -- -- - ................. ..-...- -- <br /> ... <br /> -------------------------- --1------------------- I- -- - ---.-------------•------------- ----- .............................. ------------...------------------. ...... ....... --------- --- ---- <br /> ------------------------_--_------------ <br /> ----------•---------------------------------- --------- ------------ <br /> - -- ------ ---- ------ - - ------------------------- ----..---. - -- ---------- <br /> Final Inspection by:----- . . . - .-----...._Date .. . _. . ... <br /> EH 13 24 SAN JOAQUIN LOC HEALTH DISTRICT f&S 21677 REV. 7/76 3M <br />