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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............... <br /> (Complete in Triplicate) Permit No.....-..-.~-..S.v a_ <br /> ................................ <br /> Date Issued.A.—._-1" 5 <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.fs made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION- ©-........ -- - -- { .....CENSUS TRACT.. <br /> 00, <br /> Owner's Name.- --- <br /> Address...- �i.5 ........ . .......................City --------_Zip--------------_--_--------- <br /> Contractor s <br /> - --- --_-- - <br /> Contractor's Name........ - .1'. r1<�..::: <br /> f <br /> .. :....�s.........:......... . ....... .. ....License #.. �.��. /-..Phone. ........... ...../ <br /> Installation.will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court El <br /> Motel El Other_...- <br /> X - +� <br /> Number of living units;-------.........Number of bedrooms... ...Garbage Grinder- ----..-Lot Size.......0...{.......I—.......................... <br /> Water Supply: Public System and name---------------- ------ - -------------- ------------ --- .. --------....---- ----- ----- ...---.....-----•- ..Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loarrrn E] 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.) v <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if ublic sewer is available within 200 feet,j �} R <br /> r <br /> PACKAGE TREATMENT [ ] SEPTJC TANK ( Size c�' ----------------------- <br /> -------Liquid <br /> Capacity.....' .. Type. '' -_-._v Matarial. -- lw'�' w"'...--...No. Compartments_.-...........�..'... <br /> Distance to nearest. Well....... ....... ... ... ................Found ation../ .._.. ....-Prop. Line__.-. ......-..-. ...Q <br /> �j <br /> LEACHING LINE [ No, of Lines....... . . Length of ch fine...1. .*�±-. .. .....-.. Total Len <br /> 9th..... ---- .....- <br /> 'D' Box........... Type Filter Material.`''----��f.�Depth Filter Material.........-------------- <br /> 4f 1;.:_. <br /> Distance to nearest: Well.-�p..................Foundation... -._.-..............-.-.Property Line--.`�..................--........ <br /> 00� / r r <br /> SEP [ Depth./A........Diameter�. _' ._.Number60 0 _.............................. Rock Filled Yes No <br /> Water Table Depth. J _ .. ,---•-•-------------------Rock Size..... - -----........•--•------ <br /> i <br /> Distance to nearest: Well_.-. -----------------_-----Foundation........�_- .-.-.....Prop. Line..--.-------•--------- <br /> .-..- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...................................................Date..............- ..----------------------) <br /> Septic Tank (Specify Requirements)............... ............ .............. •--- ---Disposal Field (Specify Requirements)_...._............. ...... - ------ <br /> ---------------------------- <br /> -- <br /> -------------------- ......... .----------------------------------------- <br /> (Draw existing and required addition on reverse sidel <br /> I hereby certify that 1 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. Rome owner or licensed agents <br /> signature certifies the following: <br /> "I certify that i:n erfo manc the wo k for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject rkman m aws of California." <br /> Signed_.........---...... ....... Owner <br /> .Title ...... ....a�...... ............................ <br /> (If other than er) <br /> F DEP ME USE ONLY <br /> 2 <br /> APPLICATION ACCEPTED BY... ............ .. .. ------------ •---- - - ------- -- -..0.,?------ --DATE...--.* zS ....... <br /> DIVISION OF LAND NUMBER.----..:. QATE.... <br /> ADDITIONAL COMMENTS..................... ................ .-. ....................... <br /> ............................... ....... -----......---------------... ........ ............................-........................ ------------------------•- ----- --- ------------- --•----- <br /> ---. --------- .......... •-•:--a.--------------------------------------------------------------------------------- --------------- ,............ <br /> FinalInsp.ed+on by:----.--------- -=-------------- --_...-------------------..-.....----------------.......................... ------------Date......___----------------- t <br /> EH 13 24 SAN.JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M r <br />