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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) ermit o.. ... .-.. ...... <br /> Date Issued..... <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 /> // ......... ....---.CENSUS TRACT----------------- --- <br /> JOB ADDRESS/ OC I N._CO�a7 <br /> Owner's Name....._ . _. Phone.i!li� - 79 6�_..._.. <br /> .. +d�YtA� . ....... <br /> .... <br /> Address. ....._ Cit Zi <br /> --Z _ <br /> �- ................................... Y P - <br /> 02 <br /> Contractor's Name-_ - -. dot...........-_....- <br /> License #.. .l0.39 $/ ..Phone.5�1v5--v2_ �h... <br /> Installation will serve: Residence V[T Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other..... ................ <br /> Number of living units-- -- -----------Number of bedrooms..�.....Garbage Grinder 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 200 feet,) <br /> 11 PACKAGE TREATMENT [ ] SEPTIC TANK Size _.j .acs__'_ . .7-.�_----------------------------Liquid Depth.... ------ ......... <br /> Capacity../02©_Q-......TYPJQA0_&& �-..Material�---------.-No. Compartments............5?�........... <br /> .. <br /> Distance to nearest; Well..... --- -.-_Foundation..-/6 ...... .. Prop. Line_,;.`-4........_.__.. <br /> LEACHING LINE No. of Lines .... ------------------Length of each line. _-.- -a._...... Total Length ...................... <br /> D' Box.... _ ..Type Filter Material{&4:kj.....Depth Filter Material.. <br /> Distances to nearest: Well----- .............Foundation... /Q_.. ....Property Line...c5 ....._....._............. <br /> SEEPAGE PIT Depth.-.Z d._....Diameter....33..!_...._.Number....... ......--_---- Rock Filled Yet No <br /> Water Table Depth_----------7Q--• ------------------------Rock Size_pP.)_C.3--- ....... ......... ---------- <br /> i ` / <br /> Distance to nearest. Well.-.��. --------------------- ----Foundation.-_l-Q..... ...Prop. Line._.. ............._ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ---------------Date---------. ................) . <br /> Septic Tank (Specify Requirements)---- - -------------------•--------------------- ------- ----------------------------- <br /> Disposal Field (Specify Requirements)........ .............. ----------- ---------------- <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 subjecto�rrk-manIf Iomp nsation laws of California." <br /> Signed .A .4-C�- - /t. � Owner <br /> BY .` 1.... ............. Title.... . <br /> .... : ............... <br /> of <br /> (If other than owner) <br /> fA DEPAJtTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -- - DATE .�f ..�_.. <br /> ---- -- ---- -f-- - --- -- ---- -- --- ••--- ......-- - - <br /> DIVISION OF LAND NUMBER.. (J. .`.. -----------•S-'-.675?—f a .-Z.... ....------ -DATE. <br /> ADDITIONAL COMMENTS......................... ---------.--- . . - <br /> �1-io._`� - _ � - �.. + . .. ------------ -- - ------. ----------- - ------- <br /> ------------------ - <br /> Final Inspecnon by: - --------------------- <br /> Date ..... ".. `�. . ............. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FaS 21677 REV. 7/76 3M <br /> a <br />