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r <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------- --- - Permit No_.? <br /> (Complete in Triplicate) ------------ <br /> ----------- ---------- ---- -- ........ <br /> Dare <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 RuI and Regulations: <br /> ll s <br /> JOB ADDRESSAOCATION..... .- 1.....--- — t Lug- -..----- ---•CENSUS TRACT-------------------------------- <br /> 71 <br /> Owner's Name.... .. s.F9.------/�Ga.. .... . d a .......ca L Phone <br /> Address................ ........ ............ ----------.--. --- City--7��'AG� _Zip----------:--------- ---- - <br /> Contractor's Name... .._..-.. ..-- -a ---.---•---------------------------- --License #-CP._._. �yvz.Phone �`rV <br /> Installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--..-------- ..-..----_---------- G <br /> Number of living units:.....:... ....Number of bedrooms.---3 Garbage Grinder--------.---Lot 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 Dg 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 publiF sewer is available within 200 feet,] - <br /> PACKAGE TREATMENT [ ] SEPTIC/T�A�NyK ( ] Size..., _...... x--5 -.----- Liquid Depth.-`_5 �.............�� <br /> Capacity.. .c7 �1 ----TYpep/ t®--�StMate,ri I----------- .....No. Compaar)menu.. -. .-� <br /> Distance to nearest; Well---.. ... _ - .-----Foundation-. --,51.-.Prop. Line--- Z--------------------?mac' <br /> 1 jjjj 4 <br /> LEACHING LINE [ ] No. of Lines _.__ ------ ------ ..Length of ea h ine......-_ -�-------------- Total Lnth .. N-t�..-......-......_--__._ <br /> D' Box.....L.... Type Filter Material f .. .P.�pth Filter Material-.------.?-- --------------------- <br /> Distance-to nearest: Well----. - ---.: os�ndation-_ -zQ'--------==- ^-Property Line:. ' -- •--•_ <br /> SEEPAGE PIT [ ] Depth.......... .....Diameter------------.......-Number-----------------•-------------- Rock Filled Yes ❑ No <br /> WaterTable Depth.---------------_-- --------- ----------Rock Size--------- -- ----------------------------- <br /> Distance to nearest: Well--------------.......---------------.......Foundation_'......----- - ---.Prop. Line---------------....------. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................................... .... _--------Date----------.----- --------- ------------) <br /> Septic Tank (Specify Requirements)..................... .. ------.......... .....I....... ----------- <br /> Disposal Field (Specify Requirements)---------------- ----- - --- -------------------- <br /> --...-•-----•--..._---------------------------------------- ----------------------------------------- ------- --------- --------- ----------------------------------------- --------- --- ---- -------- ------ <br /> (Draw existing and required addition on reverse side) " - var <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 subjec o�or� Compensation laws of California." <br /> Signed- . . :1:,✓ - .............Owner <br /> - <br /> BY------------------------------ ------- ----...Title.------- -------------------- --------- ----------- ------ <br /> [If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- y--- ------------------------- -------- - ---------- - ....DATE - 6. J.. .. ---7- ---- ----- <br /> DIVISION OF LAND NUMBER_-... ..............DATE---- - _---------- ------ - ------ <br /> ADDITIONAL COMMENTS-...__-............ ---------_........... ....... <br /> --------------------- - - - -------------------------- ......... ------------.....--- --..-..----------- --.-------- ---------------- ------ ------ <br /> -----------------I--- ---- ------------- .............. ---- --- -------•---------­--­-------------- ----------------------------------- --------------- --- -- <br /> -- --- <br /> ----. ----- --- _ <br /> ?_ �... . / . <br /> Final Inspection bY:------ . -- ------ - - ----�- --- --- ------�-= -- <br /> --- ------ --- <br /> - --- ------- --------------- -----..Date ..-- <br /> �-_:�.-- <br /> ---... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />