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FOR OFFICE USE: FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT "` <br /> (Complete in Triplicate) Permit No.. _. <br /> Date lssuedv,' -f, a�7 <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 /> _ <br /> JOB ADQRESS/LOCATI - <br /> 41.4NSU- S TRACT------------. <br /> ---------'- <br /> Z4 --- <br /> AP <br /> -.Phone.--.,Owner's Name._. ... Q .Address U - rP.vc C . �. -- Zip... <br /> _ . ..----... ............? rY <br /> Contractor's Name--- - .. --------------------------- -- ....._..._.... -- ---.license #-----------------------------.Phone_------------------ <br /> Installation will serve: Residence r�`AApartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Q her........ . - - ...-...--.. <br /> Number of living units:......./.......Number of bedroom._ ..Garbage Grinder--_,-Lot Size _ ` --- <br /> Water Supply: Public System and name-- ----- ------- ------ ------- --------- -- ------------------............-- ----------------- .... ... -- --•-- -----...Private ❑ <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 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 200f et <br /> � _�- j -----------G/ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ' Size. -._C d <br /> Capacity...... ..............Type.... J Material.----------- - -----------No. Compartments-------- _31U --- --- --- <br /> Distance to nearest: Well---- .. .. Foundation__�U . -- .. Prop. Line__....._. <br /> le <br /> LEACHING LINE No. of Lines <br /> �..._..-.. Length of each line........7-d -------..._Total Length .. ..�.L..d..................•_-''b <br /> GG rr <br /> 'D' Box...../-,...Type Filter Material , l.�_4�1 4epth Filter Material_. .......�.�- -_--------------------------------- <br /> -------- <br /> I <br /> Distance,to nearest: Well---..�_Q........... Foundation.....7 0--------------Property Line <br /> SEEPAGE PIT [ j Depth.-..__...- .. Diameter--------------------Number- ..--------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth---------------------------------------------------------Rock Size_------._......... . --- -----•-•------------ <br /> Distance to nearest: Well-------------------------------------------Foundation ....-----...........Prop. Line--------.----.------------ <br /> REPAIR/ADDITION {Prev. Sanitation Permit#-------------- -------------------- ---------------Date.------------.----------------------..--.------I `T <br /> Septic Tank [Specify Requirements)---- - ------------------------------ ................ ------------------ <br /> Disposal <br /> ------------- -Disposal Field (Specify Requirements)..............:... -------------------- ----.--- <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. Horne 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-)to Workman' ompensation laws of California." <br /> Signed'......... "."`... ------ 1 ---- -------------- -- .---Owner <br /> By................................................. -----------------------------------Title............... ...................... <br /> (if other than owner[ <br /> fORj6EPAU*t4Tj USE ONLY <br /> APPLICATION ACCEPTED BY------.. >Z0. . ..-- QATE _._-..... _ . . ............. <br /> ------------ <br /> DIVISION OF LAND NUMBER.-- -------- ------- DATE.--- ---- ---- - <br /> ADDITIONAL COMMENTS.- -- - ----- .. ----------- ------ - ------- <br /> ..................................... ............................... .................. ------------ ----------- - - - .....-........ -...------ ----------- -..-...._ ....... <br /> -------•-------------------------- -------- --------- --------------•------------------------ ---- - ----------. ------ ----- ------- --...... <br /> ---- ...........­•------------- --- <br /> Final Inspection by:.... ®. r.- . .._.-. Date... �� ~� .---- <br /> EM 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 717E 3M <br />