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FOR OFFICE USE: FOR OFFICE USE: <br /> r 3 Q APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> Ll 1 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 ith County Ordinance No. 549 and existing Rules and Regulations: <br /> 4' <br /> JOB ADDRESS/LOCATION <br /> -3... <br /> ... .- r. ��'q <br /> .. ...--- --- --------------- ..-- . -------------------------- <br /> .............. <br /> - CENSUS TRACT.................. <br /> Phone-------------------------------- <br /> Owner's Name.... ----- - / .� <br /> Address--------------- -------- ...--Zi ---------------------- <br /> Contractor's Name......-- �. <br /> License #.- - .� ......Phoneyl�. r�± Cl6 <br /> Installation will serve: Residenc `s Apartment House ❑ Commercial F-] Trailer Court Ele7Motel ❑ Other............... ......---------------- ----- <br /> Number of living units:.---- ./-....-_-Number of bedrooms.... , -� .- ! 5 ----------- ---- -- <br /> ( �Garbage Grinder.......-...-Lot 5ize...r�..- .. <br /> Water Supply: Public System and name................. ..... 0 A ....... -------..Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ • Peat ❑ Sandy Loam C] 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.) W <br /> NEW INSTALLATION: (No septic -tank OF seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.....-- --------Liquid Depth..................... <br /> ....'- <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' Box.......--...Type Filter Material...-.. ..... .....Depth Filter Material. -.----..-................------------- ---- .................. <br /> Distance to nearest: Wei l---------------------------Foundation----------------------------Property Line...-----..--_--------_----------. <br /> SEEPAGE PIT [ ] Depth.........-------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No❑ <br /> Water Table Depth.................... --.........Rock Size. -.-------------------. --------- <br /> Distance to nearest: Well...........................................Foundation........-------- -- --- Prop. Line........................... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------ ..... ...............Date----.-..--...-..-------------------.---..-----] <br /> Septic Tank (Specify Requirements)----.-.... -4----------- ---------------- ---- ------------ <br /> r <br /> Disposal Field (Specify Require entsl.... � � - .._.. - �l J� <br /> �r <br /> -------------------- --------------------------- ------ ------- - ----------.................... ---.....- _ -- ..-- <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 subje t orkman Co pensation laws of California." <br /> Signed--------- J' - ----.--. ,...- '' ......Owner <br /> By.. �• �t ..._ Title-------- <br /> (If other than owner) l <br /> FO DEP RTM T USE ONLY <br /> APPLICATION ACCEPTED BY.------ -1_ _i� <br /> ................. •- -------- -DATE .----.--.?-D -� .....---...--..--.. <br /> DIVISION OF LAND NUMBER.................... ................ ............. ..--- DATE.----------------------- <br /> ADDITIONAL COMMENTS. ... ------. <br /> -------- ------------------------- --- ---- <br /> --•-••------------:--------------- -- - --- --- ----------- ----------- - ----------------- ------------- ----- ...--- -- -- - ---.. . ------ <br /> ... ..- ------ <br /> FinalInspection by:.. c5�15 -------------------------------------------------------------------------------- ----- ---Date. ��.-.........--....... <br /> EH 13 24 J SAN JOAQUIN LOCAL HEALTH DISTRICT F 5 21677 REV. 7/76 3M <br />