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FOR OFFICE USE: FOR OFFICE USE*.- <br /> APPLICATION FOR SANITATION PERMIT - <br /> ----------------------------------------------------- - <br /> (Complete in Triplicate) <br /> Permit No.- 7�- �-' �; �7/,7'�X <br /> _ ' <br /> }} n Date Issued------ :�._77-- -( � <br /> ----------------- ... .L--�1---------- ------ 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 - - .............. <br /> ..--' - --.. . ENSUS TRACT------------------------ <br /> Owner's Name - - - ----------------- -------------------------------------- --------------------Phone------------------ ------------- <br /> :7 <br /> ---- <br /> Address <br /> Zip----------------------- <br /> -� <br /> Contractor's Name_. <br /> -- ----: - --(_,. .License -4--- - ------------------ <br /> Installation will serve: Residence [�]� Apartment House ❑ Commercialf❑ Trailer Court E]Motel ❑ Other - <br /> -----:-------- --------- ---- <br /> Number of living units:------f-_-_-__Number of bedrooms.-3-----Garbage Grinder-_ Lot-Size____:.'______ __________________...._...-- <br /> ti a <br /> Water Supply: Public System and name ---------------------------------- <br /> ---------------------. ---------------_ . . =... ... .--------------Private <br /> Character of soil to a depth of 3 feet:Sand ❑ Silt❑ 'Clay ❑ Peat❑randy Loam ❑ Clay Loam ❑ <br /> Hardparf- Adobe ❑ . Fill Material.............If yes,(type--------------------------------- <br /> [Plot plan, showing size of lot, location of system in relation to.'wells, buiIdings,'etc. must be.placed on reverse side.] d + <br /> NEW INSTALLATION: (No septic tank ior seepage :pit permitted if public sewer is available within 200 feet,) 1J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK '[t] ;.Size--------------------------------- - --- -----------------Liquid Depth---------------_----------- <br /> ' jCapacity------------ _TYPe---=--------- -'. Material------------------------:�!No. Compartments-------------- -------------------- <br /> Distance <br /> ----------------Distance to.n.'earest: Well-'-----------------------f=� -----'------Foundation-:------ `" ' --------Prop. Line......._....... ----- <br /> LEACHING LINE j a Na. of Lines_ _ ..- Length of each lin&------------------ . Total.Length.___-:................................... <br /> 'D' Box------------T a Filter Material- ----- -----------`bepth Filter Materid <br /> Type -------------------------------------------------------------- <br /> : <br /> r Distance to nearest: Welles __----- =--Foundation--^ - -- Proprt ---y-Line:._._. <br /> SEEPAGE PIT Det Diameter--------- <br /> __.---------Numberr ._-____ ----------- ------ Rock Filled Yes ❑ No <br /> Water Table Depth-------- :----------- -------------------------------`-'Rock Sizer------- �-- <br /> Distance to nearest: Well..!__-_ _- -__ '___ '.Fbundation :Prop. Line._ ------- <br /> < <br /> __ _ <br /> �.�� . • --- - ter- � .�. <br /> REPAIR/ADDITION (Prev.,Sanitation Permit# " _x__ -_` _,�s Date ----- .-_-- [ <br /> Septic Tank [Specify Requirements)__'-__.: '-�----- = -- ' <br /> ----- <br /> - <br /> Disposal Field (Specify Requirements)... ___ __:.._... ............. '....: __: <br /> --------------- z --- ------ -- - -i--- ---------------------------- <br /> ------------------------------- <br /> ---- --'- � -----.���.._rte.='---�------•------- - - ----- ---- <br /> i (Draw'existing and required addition-on'reverse side)r { <br /> I hereby certify that.1 have prepared this applicatiori.and/that the work "Will..be-doneAn-accordanceTwithi San Joaquin County <br /> Ordinances,' State Laws, and Rules and Regula�tioni of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in tire' performance 'of`the work for which this permit is issued, I shell not employ any person in such manner as <br /> to becWne subjeet.to Work_m_ s_C9mpensa..tion;I _of California." <br /> Signed----- - - <br /> -�.--- - .--Owner <br /> A f i ;r: d <br /> B ` Title_ __ _r' C+ x�2�. <br /> Y -----=------------ <br /> ------------i f <br /> ( Ther than owner) <br /> FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED-BY--.:- =" ----- DATE _ . -' ` <br />: DIVISION OF LAND NUMBER.. ----------------- -----------------------------------------------------------DATE-------------------------------------- <br /> ADDITIONALCOMMENTS-- ---------------- ----------------------------------------=------------------------------------- ------------------------------------------------------ -------------- <br /> - -- ------------------------------------------------ ------- ------ ---------------------------------------- ------------------------------------=-------------------- <br /> ------------------------ <br /> ------------------------------------------ --------------------------------------------' ------------------------ ----------------------------------------------------------- ----------------------- <br /> ----- -------------------------------- ------ -------- - ----------------------------------------------------------------------------- ----------------- <br /> --- <br /> --------------- - <br /> Final-Inspection,by:----- " --� - - _ ^_ ----Date----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&s 21677 Rev. 7176 3M <br />