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t FOR.OFFICE USE: FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. ------------------- <br /> --------------------- <br /> Date Issued.. --_,7.2--?- <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 /> JOB ADDRESS/LOCATION -- -- ---- � ..-.1.�_ ------------ -- CENSUS TRACT...-....-•--------- -- <br /> 0 -- ---------------------- _------ <br /> Owner's Name -. <br /> Q.�-> .............. �. ...............................Phone. p- :.. -a-fid-- ...... <br /> Address--- �{ .. ._. ... "O.. J�.1-.... Ux�� --- - --- --------- -----Ci � .... •----- --------- Zi � - <br /> tY p = <br /> Contractor's Name-- ----------- # -_..------.--------License #_---.-..-_...._..__------..Phone-------'----•-••--•----- <br /> ------------------- -- -------------- ---- • ---------- <br /> Installation will serve; Residence [3/Aportme t House ❑ Commercial n Trailer Court ❑ <br /> Motel ❑ Other........ ------ ---- <br /> Number of living units:.4,.-_--_Number of bedrooms.._.L----..Garbage Grinder-_-'-O....Lot Size'......... - ----- . -_-__-_.....- <br /> Water Supply: Public System and name-- ------------------------------- -- - - ------.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt 0-0-ay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe [j/Y-ill 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,j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ( ] Size------- -------------------------------------- -----.Liquid Depth.---:------------.------ * <br /> Capacity- -------- ...........Type.......................Material---------- ----------.----..No. Compartments------=--•------•----_---- <br /> Distance to nearest: Well-:'_ _ ----------. - ..... --------- ............Prop. Line-------.__....... <br /> --_- <br /> LEACHING LINE [ ] No. of Lines __ ----------------.__'.Length of each line.------------------------------ Total length __ ------------ ------------ <br /> 'D' Box............Type Filter Material...................Depth Filter Material.--•--...._.---__-_.......-----.,.-----:..-:----- --....-• -- <br /> Distanceto nearest: Well------------------ --------Foundation-------------...-----------Property Line-------------------------------- <br /> SEEPAGE PIT ( ] Depth................Diameter--------------..... .Number................................` Rock Filled Yes ❑ No <br /> Water Table Depth_-------------------------- --F-- -------------------Rock Sizer-_:.......... --- ' <br /> Distance to nearest: Well----------------------- -------------------Foundation---------------------.....Prop. Line........-------------- <br /> ----- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------•-----'----........-•--=-;-__._.Date-_--__-•--•-- ...-..- ---------------- <br /> Septic <br /> -- ------------Septic Tank (Specify Requirements).... .....- --- - --_-••--=- ---- <br /> Dlsposal Field (Specify Requirements) � --------•-• ....... .. .......... I <br /> ------------- -- ---------- ---•------ ---------------------------------------------- ....... ..--...-- - ....-- - ............ <br /> i <br /> -•---------------------------------------------------------------- --------------- ----------- ----- -- -----. .... ------•-•--..........- <br /> It . <br /> I <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 becoml subject to W0150an's Compensation laws of California." <br /> Signed---- -.. . -----. . . -- <br /> �.w <br /> Owner <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------... -- UN:�- -- -- ------- ---------- -`-------------------------------._DATE _.. �a_ � --.---- <br /> DIVISION OF LAND NUMBER--------- ----------- .._..... ---------- - - -------­-­---- <br /> -------- -------'---- ----- .. ------- -_.DATE- ---------_---- ----- -.- <br /> ADDITIONAL COMMENTS._CY"�G� t <br /> ------------------------- • ---- ------------------------ -------------- -------- ----------------- ----------------------------------------------------------- --------------------------- <br /> -------------- -------------------------- ------------- ---------- -_ __T ------ ------------- ....-- .......... <br /> -- .�. Date.--- - -� - - --. --- -.....--- <br /> ---------•-------- ------------ ----------------------- -- -- <br /> Final Inspection bY�-��--�-�----...--- • •- ----------•- -- �- - 1- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 inn <br />