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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. i3.1.... <br /> ...................... ........ .......... .. <br /> Date Issued.LO._,P4?:7X <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 ....... ---�L."Z ..., :... ---•-- - - -- - -------- --•----- ........CENSUS TRACT.----..... ------- -- <br /> /_ � - ---- •.... <br /> Owner's Name .. ..... . .......... ... -- --. - -------------- .........._............ - ---- Phone......�f��/� .�/.9Y_.... <br /> Address ,- <br /> City - _Zi ,S^iZ - <br /> ... Y P <br /> Contractor's Name._..._._..--. .....License #........_..------.-.---.-Phone.......:_......--.. <br /> Installation will serve; Re idence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ ..J <br /> Motel ❑ Other_ - ------- -- .................... <br /> Number of living units:..--- ..........Number of bedrooms---------_ 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 /> Hardpan ❑ Adobe ❑ Fill Material - --- ....If yes, type...... ...............--------.. <br /> L <br /> T <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 ---.:No. Compartments -- ---------------------- ------ <br /> Distance to nearest: Well---------.---..- ---- -- -_ ---- -----....Foundation......... . .... ._- .. Prop. Line-........._._.._...--.... <br /> LEACHING LINE [ ] No. of Lines . .-. -.-_................Length of each line...........-..... ......._.._Total Length _ ----------------------------------- <br /> 'D' <br /> ---.- ....._---..-------....._._'D' Box........ . Type Filter Material._..._ ----- ---.Depth Filter Material.- --- ------------- --------............... <br /> Distance to nearest: Well----- ---------- ---_.._. Foundation_-----------------------..Property Line-_--------.-.------..------•.-.. <br /> SEEPAGE PIT [ j 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 /> Disposal Field (Sp cify Requirements) - ----g-- G - <br /> ................---------- --------- ........ --'------------.---------.----------.._.------------- -----.....-._......----------............. .I----------- .------. --_---- <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 f the work for which this permit is issued, I shall not employ any person in such manner as <br /> to becaeuVecto orkm Com nsation laws of California." <br /> Signed- ------- -- - - Owner <br /> By---------------------------- - -------- . _------------- Title..-.._-.. ..............- ...----------_­----------- ----- <br /> (If other th owner) <br /> F R EPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY......... . .: ----e.___....- .-. <br /> / --------------------------- --- -DATE ----- --- --- 9- .-�`.. ... ----- <br /> DIVISION OF LAND NUMBER.... --- ... ------ --/------------------ ............... ------ --------_...._.DATE--- ----- _------ - <br /> ADDITIONAL COMMENTS-.- .. ---- ----- ----------------------------- <br /> ---------------- <br /> .49-M4. --- ---... ... . -- ------- ----------- ------ -- - --- - <br /> y---- / - : : _....--.....--- ­--­---------- <br /> ��y` .:: <br /> ------------------------------------------------- S•-T prat- -------- -... . <br /> �.y,� ___ _ ----..Date_'------------------_.-- <br /> Final Inspection by:__.... - -.-._.... - .-_ ---- -i��- -------------------- - <br /> -- - �G{-,�-�------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M <br />