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FOR OFFICE USE: FOR C]FFICE USt: <br /> APPLICATION FOR SANITATION PERMIT <br /> ••------- _ <br /> ��PrH (Complete in Triplicate) Permit No.7Y:- .4f_ <br /> Date Issued..�../ r ff <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... - .-. .. 1.1.. ......................................CENSUS TRACT----------- ----- --- . <br /> Owner's Name......--.. ............................ ..............Phone <br /> -......--..---...-- . ...... <br /> Address. ---- ... ............... City zip.............. Ii€ <br /> 1 ,q <br /> -D-------------- <br /> Contractor's Name..... _License # .. �. Phone...- ..: 1 U-1 - ' <br /> Installation will serve: Residence Apartme t House ❑ Commercial ❑ Trailer Court ❑ + <br /> M tel ❑ Other-........... ............................ <br /> Number of living units:.._ _......Number of bedrooms..... .... Garbage Grinder.....-------Lot Size.-VO-. ............. .... .. <br /> Water Supply: Public System and name------ ;._......Private ❑ <br /> ----------- ----------------------- ---------- - - <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 <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 or seepage pit permitted if public sewer is. available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANKy to ------- � .... - Liquid Depth-91 __... _--...W <br /> I ) Size ...�-i�..�--�--• - q � <br /> Capacity--l. �yrQType---•A- ---. __.. .Mat� --- ,....No. Compartments_......-P- <br /> Distance to nearest: Well-=- Foundation... d Prop. Line ~^ <br /> i <br /> LEACHING LINE ( ] No. of Lines....... �. <br /> Length of each line------------- - Total Length ... <br /> 'DBox.. ......Type Filter Material..._- - Depth Filter Materiall ------------- .. <br /> earest: Well... ----- - <br /> Distance to n1a- - - Foundation...X66----------- Pro ertY Line <br /> SEEPAGE PIT 1 a <br /> [ ] Depth..-.'r!-...-._Diameter..-��---____-.Number----�-------------------- Rock Filled Yes No <br /> Water Table Depth---------------- --------------------- ---------------- Rock Size.- �.�� .......................... . <br /> Distance to nearest: Well--------------------- ---------------------Foundation---.---------.............Prop. Line--------.-.----------- <br /> REPAIR/ADDITION <br /> -----. -REPAIR/ADDITION (Prev. Sanitation Permit#-.---.---------------------------- ---------------Date--------------.--------___-.---_-------) <br /> SepticTank (Specify Requirements).. --- ---- --------------------------------------- ------------------------------­.­------ ------------------. .............. ........... <br /> Disposal Field (Specify Requirements).---- -- -.-------------- -- ---------------------- <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.-... .. ... --- <br /> - - ----------- --------- ------------ ---Owner <br /> By..------------ --- -- ('/ Title <br /> (If other than owner) <br /> FO EPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY----- . . .. ....... .. .... '� ...................................-.DATE ...... f.1� ..7 .----................ <br /> DIVISION OF LAND NUMBER------ ------------------------- ...................DATE. ---- <br /> ADDITIONALCOMMENTS....... ........... ....... ................ ................................................... ............ ................... <br /> ------------ ........................ ------- -------------- -------- ----------- ....... -- ........._.........------­ <br /> ............................... .-... <br /> ------------------------------- ------- ... �.-..- - -------------------- ------- -------- ..-- ------ --..� <br /> Date... <br /> Final Ins ection b � � -- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV 7/76 3M <br />