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' FOR OFFICE USE; . <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> `G (Complete in Triplicate) Permit No. ./.- <br /> ---•--•-------------- -�-------------, <br /> Date <br /> --------•-----•--•------------- ------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to-the Sari 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/LOCATIO , r <br /> Owner's Name _... .. ----------- -----CENSUS TRACT:.-_. <br /> - .-----Cr--•------•------ P <br /> Address-- --- -- - � .. ane._..--- - -- • .-.--- - ---- <br /> ... }y <br /> Contractor's Name-- -- , - - �............ <br /> ... -- -' <br /> .. .....License # <br /> one- ... .. . - - - - - -- - .Ph -- ---- <br /> - ------ <br /> Installation will serve: Residence A artment House E] Commercial ❑ Trailer Court ❑ <br /> _Motel ❑ Other----- --------- <br /> Number of living units:...... <br /> --------Number of bedrooms._-- - 7-....� " ._- <br /> �arbageGri��nder____-_-__•-_Lot Size.-_�_G`,x,� - <br /> Water Supply: Public System and name?-..... Alit <br /> ----------------- •-----PrivateCharacter of soil to a depth of 3 feet: Sand ❑ Clay 0peat - <br /> ❑ Sandy Loam ❑ Clayll-oam <br /> Hardpan ❑ Adobe ❑ Fill Material.. ..."__If yes,4ype--_•_-----•?----•-_ <br /> s -------- <br /> F <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 5200 feet,) <br /> Cr <br /> PACKAGE TREATMENT [ ] 'SEPTIC TANK /� 6 T <br /> i [ ) Size `-... ...- Li9uid Depth.. ----- <br /> Capacity,f�Q ----Type- ater ial <br /> 411-^ ----------lNo. Compartments___..,_.-.- . <br /> Distance to nearest: Well__ t <br /> Foundation.......... . ... .... ....Pro Line---.... ..-----r <br /> LEACHING LINE [ ] No. of Lines .. ' <br /> th . <br /> t ----L�- " ------ . ---Total Le$.g . _-� <br /> Length of eac li -•---- ........... <br /> 1 <br /> D' Box Type-Filter Material—.-: - t..- _ Depth...Filier_Mater_ial--.-/- ----------------------------- <br /> �. <br /> Distance to nearest: Well_ <br /> F undation ------ Property Line..--•------ -- ------- --------- <br /> 9A/ �[ <br /> i I ) ep'4T1 .........Diameter ----------- <br /> ----Num <br /> berk._.� "¢ v <br /> --- —� <br /> #, Rock Filled Yes No <br /> Water Table Depth.--------- <br /> -------., - -Rock Size.__ i_ f <br /> s .. I --•-•----- - <br /> 3 :.. <br /> Distance to nearest: Well. --.------Foundation Prop. Line- ---- . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#____________________________ t <br /> Date <br /> Septic Tank (Specify Requirements)__-._-_1-----_-- s ' <br /> Disposal Field (Specify Requirements)....-_,---•••-:--:_--- - 1 <br /> _________________________ �� <br /> �. ....................................... ............. ......,....____-.____.--... <br /> ___________________ ' <br /> i <br /> � ., ___.____..__... .---._.....-_ Y --------------- _.._...__....-..--____- <br /> _________________ . <br /> __ ...._.... __��__- ._ � �- <br /> y -- � ( aw-ex'i�sfing•and required addition on reverse side) .. i <br /> 1 hereby certify jhat 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.-Home owner or licensed agents <br /> signature certifies the following: <br /> "1 certify.than in the performance of the work for which,this permit,is.issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of �Californip:" t <br /> } <br /> Sigrtied�s -_-- <br /> Owner <br /> By.,` .- <br /> -----....-.- Title--- ....... ......_._ <br /> (if other th n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ <br /> -------------- ----------------------- ------ -- -----.-DATE <br /> DIVISION OF LAND NUMBE .. ......... .DATE.---t <br /> ADDITIONAL COMMENTS....-- ----------- -------------- --------- - ---- <br /> {-------------- <br /> ..-- - ----------------- - ------ <br /> ...............----...... ------. ------- - -------------- ...................-- --- --------- ---- ---- --.... ........ <br /> ` --- ------ -------- - ----- ----- - <br /> -•----------- --•---- I <br /> ----------=-•---- -------------- -------- -------------• •---------- -- --..... <br /> Final tnspecrion by: --..- . - ..........Date <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />