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FOR OFFICE USE: FOR OFFICE USE: <br /> - <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No_7 /9 -. <br /> Date Issued-.-/-S"2f <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- — <br /> A-- ------ .-...-•---... -. G/C a`1`CENSUS TRACT <br /> .. <br /> Owner's Name.... ..... r �' Phone <br /> �= y <br /> -.--. --.......-- <br /> Address..-- ---- ...........City ...........zip------- --------- <br /> Contractor's Name........~l - .License #-.v - .. _Phone--./t-/9!�/ a <br /> Installation will serve: Residence]' Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other. ... -- ------ ..................... ,r <br /> Number of living units:....- ..----Number of bedrooms-�3-_...Garbage Grinder-_----------Lot Size----,<�-._ -�`:............... .. .- <br /> Water Supply: Public Sysfem pnd­name------ ------------ Pr <br /> ---- - - ------------------------•--------••----- --....------..------- -----. ivote , <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Pear ❑ 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.) L3� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] tl�l <br /> r PACKAGE TREATMENT [ ] SEPTIC TANK ( } Size ............. -------------------------------------------Liquid <br /> .. Depth---------- <br /> Capacity <br /> ---- <br /> Ca acitY- -- --� _---.-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' Box..... -- Type Filter Material-----....--- -..Depth Filter Material--...------------------------------------------------.,--.-.--- <br /> Distance to nearest: Well-------- ......Foundation----------------•..-------..Property Line--•-.--- <br /> SEEPAGE PIT [ ] Depth.. ...... .....Diameter-_.-..............Number--------------------.-------.--i Rock Filled Yes ❑ No ❑ <br /> r Water Table Depth..................... •-----.... =-.Rock Size...........-..-.--.. •..- <br /> } <br /> Distance to nearest: Well------.--•----------------- :.---,----_-Foundation----------- -_.. ._.._....Prop. Line.........-....--......_.... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.-----------_-------------------------- --_.Date------•--••--------...-------.---.---.---...] <br /> Septic Tank (Specify Requirements)- ......... .....*----- ........................ - ....... -_-....-� - ----- <br /> ` r �/ <br /> Disposal Field (Specify Requirements)..... <br /> -.. �� :. �' 'h •a 'r(.TL_<- --------- <br /> ----------- --------. <br /> .77. ...... S4 � ---- -- ----------------- - <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,'s.ubject to �- -4- r-k-r-rra�n's Compensation_la <br /> ws of California."�Signed ... -� -- - . ..-. ...-Own <br /> Owner ,�x <br /> ------ <br /> (If other than owner) <br /> 01�* FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY :...... :.........DATE �+� .....-..... <br /> DIVISION OF LAND NUMBER.............. DATE..................---.---- -.-- .--------.--.--- <br /> ADDITIONALCOMMENTS ..... --- -------- -------------•••--------- ................ ................ - -- ----- ----......--- ---- <br /> k <br /> Final Inspecflon by:.. <br /> ... ----------- ------------------------- -----• �� -. .. <br /> Date- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 71677 REV. 7/76 3M <br /> t i <br />