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FOR,OFFICE USE: <br /> '4APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> � <br /> {Complete in Triplicate) Permit <br /> f I 1 <br /> Date <br /> This Permit Expires 1 Year FromDate Issued <br /> Application is hereby made to the San Joaquin Local Health District fora 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:.-------- ............ _-.CENSUS TRACT_-_____-`* <br /> �11 <br /> Owner's Name- ------ - ,----- � � Pho c <br /> o. <br /> Address--- �a- - ----- ---- - -- ---- ------L.City -------�Zi.p----. ------ <br /> -- - ..hy _ _ - _O may- l. <br /> Contractor s Name-------- - - _License#� .,4 . _ Phone_- ._ __3_r �s� <br /> - � ;�; .- _ <br /> Installation will serve; Residence [y�partment House ❑ Commercial ❑ Trailer Court ❑ i.. ` <br /> F <br /> f .. Motel ❑ Other--------------------- ------------------ ; <br /> Number of living units:-----/_.,.__ -Number of bedroom s,=X_.:G--Garbage Grinder_._---------Lot Size_- __ -_ <br /> -------- <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 Fj 1i <br /> Hardpan ❑. /Adobeg 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-----=-----------------------------------------------------Liquid Depth----------''----------,-_� <br /> Capacity = Type :'' - Material <br /> ------:------ ------------No. Compartments------------------ _-° _ <br /> F ' <br /> Distance to nearest: Well--------------- <br /> ---------Foundation------- -------Prop. Line-=--------- ------------- <br /> f <br /> LEACHING LINE [ ] No. of Lines_ ---------------------------Length of each.line.____________._______.___._.Total Length--------------- <br /> ------------------------- <br /> 'D' <br /> __...____________- :____'D' Box.------- ---Type Filter Material---------------------Depth Filter Material--------------------------------------------------------------- <br /> Distance to <br /> -------------- -_------ <br /> Distanceto nearest: Well---------- ----- <br /> ----- _____Foundation..___._-._,--.----___.______Property Line--------- -_-__--___.____-__- <br /> SEEPAGE PIT [ ] Depth------------------Diameter----- <br /> 1--------s----Number ___ Rock Filled ' Yes ❑ No ❑ r <br /> Water Table Depth --. <br /> :-------------j- --------------- Rock Size <br /> Distance to nearest: Well_----;---------'------------------------_---Foundation-------------------------- Prop, Line__________-_____........... <br /> . <br /> REPAIR/ADDITION [Prev.Sanitation Permit#---.---.___-'---------------- --------------------Date__.---------.----------------_----------------1 • .` <br /> Septic Tank (Specify Requirements)---- Qd.-_. _ __ _ _ _ D /z7 <br /> ate,; = <br /> Disposal Field (Specify Requirements)______________ __ --------------------- <br /> t <br /> • 4 <br />- ___________________________________i_---------____-_-------------------------------- ___.__--.-_-__________'____________.___.__--.,_--.._._________- --- .___'F__ _ <br /> [Draw existing and required addition on reverse sitoll <br /> 411 hereby certify tha ve 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:. O <br /> "I certify that in the performance of the work for which this permit is issued, I shall n8�mploy any person in such manner as <br /> to become +'ect to kman' Compensatio-n laws of California:' r , <br /> Signed w �- ' Owner ` ' <br /> J ,- <br /> - ----- - -- <br /> By* ----- Title-. --------------- ---------- <br /> (If other than owner) Y <br /> `FOR DEPARTME T US LY <br /> APPLICATION ACCEPTED BY-------------------------------- <br /> DIVISION <br /> - ------------ ------- -DIVISION OF LAND NUMBER - t-- ------------------ ------ --------------------- --------- ---.-_-- :------ -DATE-------------------- ' <br /> ADDITIONAL COMMENTS------------------ -. = x ' , <br /> - -------- --- ------------------------------------------ ------------ <br /> ------ <br /> ------------------------------------------------------------------------------- <br /> ----------------------------------------- ------------- --------------------- -- <br /> --------------------- --- -------------------------------- ------------------ <br /> --------------------------------------- - <br /> I <br /> --------------------------- <br /> Final Ins ection b ----------- �-------------------- — — 1 <br /> -------- - - - ------ <br /> PY --------- --------- Date- <br /> --- -------------------- <br /> Final <br /> --------- -- -- <br /> EH 13 24 SAN JOAQUIN LOCAL HEA DISTRICT • F&5 21677 REV. 7/76 3M <br /> pr <br />