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FOR (� FI,CE USE: SCR WFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------- <br /> (Complete in Triplicate) Permit No. ... .-_-..�� U <br /> _.7.� <br /> --••-•----•-•------•-----�... .......... .........•-- -- <br /> ----•-•--••••..---•-•-•................ .............. This Permit Expires } Year From Date Issued Date Issued..y�_.-._.T' <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........�_.Cl _------------ - -.-�ENSLIS TRACT........... <br /> ------- ------- <br /> Owner's Name.. ------ - ------------ ................ .....................Phone_.............. ....... ..... .. <br /> Address----------- - ----- City....--- ..-----------.. ---...------ -- --ZiP-----.------..._.............. <br /> Contractor's Name........ .. .. . ....' .... _ ...__ .... icense0130, VMPhonelevZ,377f 7V2, <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other . ....... ........... .••--•--------------- <br /> Number of living units:........ _----Number of bedrooms-....7--Garbage Grinder------------Lot Size................ <br /> Water Supply: Public System and name.. .......... ---- ...... ...... . ...... .• --•----------------------- ._..... -------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand X Silt❑ Clay ❑ Peat ❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is.,available within 200 feet,) <br /> PACKAGE TREATMENT [ j SEPTIC TANK Size - (f - -- -.----- -------------------Liquid Depth.._V/._ ._........ <br /> Capacity- - -- --------------Type--------.egthof <br /> Material ---- --- ._No. Compartments..-...q 9y <br /> Distance to nearest: Well.�,-.1_C -......----------Foundation...... .....- -- ...Prop. Line............ <br /> .-..----..--..- <br /> LEACHING LINE ( I No. of Lines .. .. .........-...........Leach lies------------..-----------.--- Total Length .. ...._.....-_..................-.-•- <br /> 'D' Box--....... ..Type Filter Material................... Depth Filter Material........................_....-____..........-.-.................i" <br /> Distance to nearest: Well--------------------------- Foundation..------------..-----.--.-.-Property Line......----------------------....... <br /> SEEPAGE PIT <br /> [ 1 Depth.............. Diameter-----------------....Number-------------------------------- Rock Fille-d Yes ❑ No ❑ <br /> WaterTable Depth----------------------------- - -- --- -- -- ------------Rock Size----- ---.... ------...----------.....--•---. <br /> Distance to nearest: Well...........................................Foundation--....-.-.........--......Prop. Line------..--_..------ <br /> .--.-_-- <br /> REPAIR/ADDITION {Prev. Sanitation Permit# . .................... De...................... . } <br /> Septic lank (Specify Requirements)..... -4 . <br /> Disposal Field {Specify Requirements)_.-----.-.��0---- -- --------------------- <br /> •- <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 subject to Workman's Compensation laws of California." <br /> Signed._.. - ----------................. ....... .....Owner <br /> By..--- ------ Title.- -_-------_--- <br /> other than owner) <br /> R PEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-..-------- ..... ------------------- ...----..DATE ........ .y - .......... <br /> DIVISION OF LAND NUMBER.- D E <br /> ADDITIONAL COMMENTS 2A ........s.4 _. M ... .. /.._ <br /> ----------- <br /> cA � - <br /> ----------­------------------­ ---------------- ------------------------ ------------------=---------------------- .................-- . _---------------------- ..................... <br /> ---- .._..---•----------------- ------•--•...................... - - ------------------ -- ---- ................. <br /> Final Inspection b � ---------------------- --- - Date.- -� ........ <br /> Y <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FGS 21677 REV. 7/76 3M <br />