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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- (Compere in Triplicate) Permit No... .......... ........ <br /> 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 /> JOB ADDRESS/LOCATION----- a.7._®..... .1�A. -�.tt�i.Q. � l�- --------------•------------- ------CENSUS TRACT......----_-----_-_-------- <br /> Owner's <br /> --:_----- ---.._...---.Owner's Name.... .&&,4r------?P7a—.,r�. . ' ............. .......•-................. ---­-------- -----Phone. ...... <br /> Address----------------So2YO. > ✓� ------------- -----------City--S�vC_ �o-�s.�._.. -- - ZiP <br /> ---- ------- <br /> Contractor's Name..__.L. _ _. C...,g.a7t4___.___._......-_.------License <br /> ?..... <br /> Installation will serve: Residence.n Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other. . ------------ .................. / 9" <br /> Number of living units:.-- 1------Number of bedrooms... Garbage Grinder............Lot Size.--- /.....®2. ._.0 ........... _.._ O <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 /> 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 sewer is available within 200 feet,J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ------------------.-----------...:...... ..._ -----------Liquid Depth---------- ----_---- <br /> Capacity-----_ <br /> ---_....Capacity------ - ------- ---Type.......... ------------Material_..------ ------------.--No. Compartments_.... ...-----......------------. -t <br /> Distance to nearest: Well. _......._..____.. _................Foundation...--...-- . ..._..... _.Prop. Line.._-----..__.---.......... <br /> LEACHING LINE [ ] 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 /> WaterTable Depth---------- .............-_.......- ----------...........Rock Size------........__..... ----------- .----- <br /> Distance to nearest: Well __ Foundation......----------_..---...Prop. Line........__--------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................................... .-------------.Date.............-------------------...._..__.. -- <br /> Septic Tank (Specify Requirements)------ - ----- ........ ---------- <br /> �^-- -- ----------------------------------------- --- ---------............ -------... - ---------- <br /> ''JJ® '�� <br /> Disposal Field (Specify Requirements)__- .. ..`7.. .._ .___-------------------------------------------• <br /> ---- ------------ -------- -- ---..---------------.�----.3.-----x ��� � -------- <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, 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 /> By..--- .; -- <br /> -L/.... .. Title.._.._ -------------------------------------.:. <br /> (If other than owner) <br /> FQCDEPARVAENT PSE ONLY <br /> .. ., <br /> APPLICATION ACCEPTED BY-.. -. �:: DATE . --2 -- --- . -- ..----- <br /> DIVISION OF LAND NUMBER. - __...... .-- - DATE----------_----------_------- ................ <br /> ADDITIONAL COMMENTS--.................._...._ •---- ------ ----.. <br /> -•---•-••-•-•-•------------- --- . .... --------..... ......... -------- -•-------------------- ---- ------ ---- _.- ------------- ----------------- ------............__ ....... ------ -- ..------ <br /> ....................•------------• ----... --- --- --- ---- ----.................. -•---------- ------ .....................-....-----------............-----------•----------......................................... <br /> ..-•-•..................•-•----- <br /> Final Inspection by `�\. . - --- --------- ------------------• --------- . -- . ---•--------------------.Date. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M <br />