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FOR OFFICE USE: y FOR OFFICE USE: <br /> �. APPLICATION FOR SANITATION PERMIT <br /> ----- . 7�I <br /> fi (Complete in Triplicate) Permit No A- ... ...: . ........ <br /> Date Issued_.._-2Z,- / <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 wit Count Ordinance No. 549 and existing Rules and Regulations: <br /> !OB ADDRESS/LOCA ON - �_ ------ --------CENSUS TRACT .....---- <br /> Owner"i Name.'.:: . - Phone /J ` • "" 3�? <br /> 5-. S y� . _.`City. D-C' ---Zip- - , <br /> - - <br /> Addres <br /> ------_-- <br /> Contractor's Name......... -License #.-36.3.9*/. Phone <br /> Installation will serve: Residence" Apartment House ❑ Commercial ❑ Trailer Court 1] <br /> Motel 0 Other - - - -- ...... ------ --------- <br /> Number of living units: .:.../.....Number of bedrooms..--ff_...Garbage Grinder------------ Size--- <br /> .- _........ .. <br /> Water Supply: Public System and name + _ -�C----------------------•--- . ...... -----------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam 0 Clay barn ❑ <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,) Q <br /> PACKAGE TREATMENT [ ) SEPTIC TANK I ] Size-------------------------.--------------------------------------------------------------------Liquid Depth.­. <br /> Type--------..... .........Material--------------------------No. Compartments............... --...-------------- <br /> f� <br /> s Distance to nearest: Well.:...................... .------_--------Foundation..-------- . -.-- -.-- -- Prop. Line........-... - -............CA <br /> LEACHING NG LINE [ ] No. of Lines .........------Length of each line------------------------- ---Total Length . ----......- - - <br /> 'D'.Box----.... ...Type Filter Material- -.------ .. -....Depth Filter Material........................ ...................................... <br /> Distances 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 /> .--.-.) <br /> Septic Tank (Specify Requirements)------------------- <br /> ------_ --. --------- •_...s{.................. <br /> Disposal Field {Specify Requirements)_ .. <br /> equirement )...� .... � ..__ .. .... .-.� ° ."�--.5. ... ...... <br /> k------= -------------------------- -- ----------------------------- ......................... - --------------.--------- <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 subley—to Workman's Compensation 'laws of California." <br /> Signed - ...b �� Owner �J%1' <br /> v-'" <br /> - <br /> By........ ....--•-------- -- =._.Title . <br /> (If other than owner) <br /> DEPARTMENT/U$"Njt <br /> APPLICATION ACCEPTED BY------- .... ------ ----------- - 1' `...----- ... --.DATE..... .... <br /> . .��.--" ........... <br /> DIVISION OF LAND NUMBER--------------------- ------.-....-.DATE ......._......... .I <br /> ADDITIONAL COMMENTS - - --------------------------------- ---------- -----------------------------.-._.--- --.......... <br /> --•--....---•------- ... ------ . -------------_--.-- <br /> - <br /> -------------- <br /> t <br /> ------- -- ------ <br /> F2-inal,Inspection�on hy: .L/.�. 7am <br /> " 13 2" SAN JOAQUIN LOCAL HEALTH DISTRICT F&S X1677 REV. 7/76 3M <br />