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FOR OFFICE USE: FOR OFFICE USE: <br /> 11 APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No....7,-f- ---. <br /> ­------------­--------------- - <br /> Date Issued--.................. <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to-the Son 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. -�-�..r��7_�-..... ............ /.. .`-------------_-------------------CENSUS TRACT----------- ------ <br /> Owner's Name t .- "----• A�.ri.. - ---------------- <br /> Address..------ ... -- - Zip-- <br /> ...... ---- -- ... -----Cit ------- <br /> 3 Z a-- - <br /> ­ <br /> Contractor's -License #--------- - ------------ -Phone-------:--------------. - <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> E Motel ❑ Other------- ----------- - ------------- ---------- <br /> Number of living units;-------1.......Number of bedrooms-.cel---....Garbage Grinder--------..--Lot Size-- �.`�1 ' <br /> Water Supply: Public System and name.............. .:-_I - -- ....... --------------------•-•---Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat ❑ Sandy Loam [] Ciay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.- .... -...If yes, type------------------------- C <br /> 1 <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 [ } SEPTIC TANK [ ] Size ---------------- ............---------------------Liquid Depth----:.............. - -- <br /> Capacity..... -Type-----------------------Mate-rial---------- ..-.-.-:No. Compartments---- ..... .............. <br /> Distance to nearest: Well-------------------------- -----...-......Foundation..---..... -. . ........Prop. Line----- .----------- <br /> LEACHING LINE [ ] No. of Lines ............................Length of each line--------------------------- -- Total Length _.. ....................... N <br /> t, <br /> 'D' Box- .._-- --Type Filter Material- . --.- Depth Filter Material--...................-------------------------------...--.-- <br /> Distance.to nearest: Well------------- ----- - 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 /> SepticTank (Specify Requirements)......................................................... .... ---------------------- ------- .......------_----- ---------------- ------------- <br /> Disposal Field (Specify Requirements) d4 `-...C/ --...�-.1 ./.� . <br /> U _ " 1G' <br /> ------ ---•---•--------------- ----------------•------------- - ........ .....---.................... . .... <br /> ----------- -•---•----......... -------- ................ ----------------------------- .........­­ - ---------­_­------- ....................... - ----------- ---------- <br /> (Draw <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 Jogcluin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I! certifythat in the � <br /> performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to bec a subject :m s pensation laws of California." <br /> Signe --. ------ <br /> By- <br /> •BY -------- - --------------------------------------- -Title-- <br /> (if other than owner) <br /> k. <br /> FOR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....................... -DATE ..r� �' <br /> DIVISION OF LAND NUMBER.-----................. . - ..-----_.DATE------.------------.- <br /> ADDITIONAL COMMENTS-- -- ----------- - - -------- ----------- ---------------- ----- -- ----.. <br /> ........... ........ ---.....----...-- --- ---------.... . .......... ...-.1....-------- ------ <br /> ----------------------------------- - --------- -------- ------ ....._ <br /> /1 ... <br /> Final inspection b - ------ - -� - --- ------- -------- ---- --- —' f r <br /> ...Date.- -------- ---- <br /> i E" 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT A41J J F&S 21677 REV. 7/76 3M <br />