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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> "--------------------- D <br /> (Complete in Triplicate) � Permit No...7 7- -�--.- <br /> ----------------------.--------------------------------- <br /> Date Issued_j 1" <br /> -.____--._.._.-_--___.__.___------------....... This Permit Expires 1 Year From Date Issued .l._.__7 7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> phis application is made in compliance with <br /> QCounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC�ATION. 3- -------__ ----------------_--..---.------._CENSUS TRACT-___-______! t� <br /> Jwner's Name---C-.'"J"'-_,. --/ -- - -----Phone -� �7-'1 _T._ <br /> n - - - ------------------------ - --- -- ----- <br /> r.reddress---r �._L t xEC7- `L'- -.... - --- -----------.City--✓�'`-------- -- �-----------Zip-------------- - ---- <br /> y� N <br /> Contractor's Name--- � -. r--- ------------ - - - - _ - _ .___..._.__License #.��Q-'¢�-._Phone.7f.-.��._�.�__�"sl'..... <br /> 'nG - - -: .-- - - - -- <br /> Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> -. Motel ❑ Other---------- - __ .-_----- ------ ------- <br /> Number of living units:_-------------Number of bedrooms-./74 ..__Garbage Grinder-----___-Lot Size--------- ------_.___._.._--.._-__--._---__-_.___. <br /> Water Supply: Public System and name------------- ------------------------------- Private 93 <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material------------If yes,type_.........----------------_..- <br /> (Plot plan, sholwJ-� size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALL616N: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> 6.PACKAGE TREATMENT [ ] SEPTIC TANK [ ] © Size---____-_..-_--__-__._-_-_.._______._-______---_Liquid Depth. <br /> Capacity�pl �7'-Type.--4± !_-Material_-_._.________________No. Compartments_ '7v-----_-_---------_._� <br /> S <br /> -, - Distance to nearest: Well-------1/�/° _-_-__---_-____---__Foundation_-Me----------------Prop. Line--------- <br /> -LEACHING LINE [ ] No. of Linesy'__ ------------ -------Length of each line_h------ ----------------Total Length. ------------------------- ILI, <br /> r r <br /> 'D' BoxJ--------Type Filter Material- -----Depth Filter Material__- -_--__---__-_.........................._ <br /> Distance to nearest: Well--------------.---------_.Foundation----.------------.----------.Property Line------------_- --------- <br /> _ _ _ _ ------ ___ _ <br /> SEEPAGE PIT <br /> Depth-.--_.- ____-Diameter--.- __-_____._ .Number__.- ___ ___- . Rock Filled Yes ❑ No ❑ <br /> [ ] Water Table Depth------------------------------------------- ------ Rock Siie--------------- -- - ------------------------ v <br /> -� - Distance to nearest: Well------------------------------------------Foundation-------------------------Prop. Line--------_-- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_..____----------------_.__._-___..____.Date-____:----------.----------------------- ._I <br /> Septic Tank (Specify Requirements)------------------------------------------------------------- -=_=---------------------------------------------- -- `------- 1 <br /> Disposal Field (Specify Requirements)----------------- ----------------------'------------------ -------------------------------F <br /> v <br /> Im-----------------------------------------._ <br /> ------------------ ------------------ --------`---------- ---------------------------------------------------------------..------------------- <br /> (Draw existing and required addition on reverse side) <br /> 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 , _ _ <br /> become <br /> et subject to Wo kman's Compensation laws of California." <br /> Signed 9- - _- ------ <br /> _.._ Owner <br /> BY-- ---- -- --------------------------------- Title __ _ - - <br /> r (If other than owner) <br /> 42) XOR DEPARTME USE ONLY <br /> APPLICATION ACCEPTED BY-------- - - ----------- - ------r t- -DATE.. <br /> DIVISION OF LAND NUMBER. --- -- ----- " --------.DATE.----- -- - ------------------------------- <br /> ADDITIONALCOMMENTS------------------ -------- ------- -=--=--- ----=---------------- ------------------------------------------- - <br /> -._ <br /> - .._.. ---------------------------------------- - -------- --------- - -----------------------------_­------------ ----•------------------ ----------- --------- ------------ <br /> - - -- ----- ---- -- - - - <br /> ---- --- -- ------------ <br /> - - - - <br /> Final Inspection by:-------- - - ---._.. -- --- - -------- --Date. .--- ------- ---- <br /> EM 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.7/76 3M <br />