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„, ; ,�• FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT : <br /> (Complete in Triplicate) Permit No..�,l <br /> ...............................-...... ........... <br /> ............................. ................... This Permit Expires 1 Year From Date Issued Date <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.. __,&Z- --- -..._ -------- - ...._CENSUS TRACT............... ------- <br /> Owner's Name.... .--.- _.. lc� S ala <br /> �✓ -- --- ---------------..---• --- ------ -.--• •-• PhoLfe " ... <br /> c� <br /> AddressQ� ... [ City -- - ...... <br /> - .. - <br /> .on a <br /> Contractor's Name--�._..” &4 ...-- ..... ...............License #- 340-+33 � ....-Phone-.�d/�-.S P F / ...... <br /> Installation will serve: Residences" Apartment House ❑ Commercial ❑ Trailer ourt ❑ <br /> Motel ❑ Other.................... <br /> Number of living units:....../......Number of bedrooms...� Garbage Grinder- --- ----Lot Si ���.X..�.d5_�,--- :.-- <br /> Water Supply: Public System and name---------- l� Q .- _ -------- ----- ---- ---- -- ----- .. ............. -----------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ dy m-❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material.- -... if yes, ty ----- ---------------------- - <br /> {Piot plan, showing size of lot, location of system in relation to wells, building a must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if pu lic er is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] - Size............... -- -----------------------------------Liquid Depth------...-.......... <br /> Capacity------ ------- TYPe---------- - --....Mat i ---No. Compartments -----.-•---- <br /> Distance to nearest: Well-------------------------------- ----- ---Foundation.... ----.. .. Prop. Line-----------.------------ - . <br /> LEACHING LINE [ ] No. of Lines..---------.......-...-......Length of a I' s....---..---------.------...-- Total Length -. ............--- <br /> 'D' Box............Type Filter Material-------- -- ---- - Depth Filter Material..................___.................................... - <br /> Distance to nearest: Well........•--------- oundation----------------•-----------Property Line................................... . <br /> SEEPAGE PIT [ ] Depth................Diameter..---------- .. -. mber-------------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth------------------- ---- -- -------.Rock Size----------------- - ----------------- ------ -- <br /> Distance to nearest. I ---------- -- ..........................Foundation................ .........Prop. Line-------...-----. - - -. -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-- --------------- --------------- ----------- _Date--------------------------.-------.-----------) <br /> Septic Tank (Specify Requirements)--- -- ----- ------ ---- --- ---- ..........------ - - <br /> ---- ---- -- ---- ..-.....-- ---­--­ <br /> Disposal <br /> - <br /> bisposal Field (Specify Requirements)----- Q�.. -- - - - --- E ' -- ---------------- <br /> to. <br /> ... <br /> - ------------- -------------------------------------- .­----------- ------------------------- ----- - ----------------------------------------------- --- -..._..--------.....-...... --------- <br /> {Draw xisting and required addition on reverse side) <br /> I hereby certify that I have prepared this plication and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules an 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 a work for which this permit is issued, l shall not employ any person in such manner as <br /> to become subject to— orkman's ompensation laws of aI f rnia." <br /> < A - <br /> Signed--- .`(l a'r?. --Owner <br /> By---------------- ---...Title ..... ------------------------------------------- <br /> (If othe than owner) <br /> 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 1 ----•-------------------- ---.. -- ---- ..................-DATE ----- -- <br /> DIVISION OF LAND NUM R. -....... --a----- -- ------- ------ ------ DATE..-...-............ .............. ............. <br /> ADDITIONAL COMMENTS-- ------------- - - <br /> -- ------- -------- - ---.......-- .... ............................. <br /> --------------------- ------------- - ------......... ............................--•----------------------- <br /> Final Inspection b Date ---------------------------.---.--.------------ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />