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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT - <br /> �-- _��.�.' <br /> - ------------ --------------- - ------------- (Complete in Triplicate) Permit No. <br /> _--- ------------ ---- -- Issued-- <br /> ------------ <br /> Date Issued-- <br /> ---_---.---_ ---------------- - — <br /> r 7� <br /> This Permit Expires 1 Year From Date Issued 0 <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 /> ' rr�/� t. <br /> 0 <br /> JOB ADDRESS/LOCATION �� / ---t ----------------------------- - -CENSUS TRACT----- -- :--- ... -- ----- <br /> `���-- �----/� --- -- ----------- -- --- <br /> J r <br /> ' � �. `- <br /> � <br /> `� �' <br /> Owner's Name... -- --- --------- ---------------- ----- ----- -----.Phone.-- - -------------- <br /> � <br /> tr `�� --...City-..-- <br /> --------- <br /> City - --------Zip ------------ <br /> s <br /> Address--- r 7----- ";� - .. <br /> - <br /> Contractor's Name---- `{=r� - `.=t C ,.--------- License #. Phone_.- -, -.: '�r' <br /> ------------- ------------ <br /> installation will serve: Residence P-__-Apartment House ❑ Commercial ❑ Trailer Court ❑ Q <br /> Motel <br /> ❑ Other------- --------------------- --------------- <br /> - "------- --- � <br /> Number of living units of mLot size.---- �E`6-IL---:-O-`------ �------ -- ------ <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 ❑ Fill Material_---------If yes, type-------------------------------- C� <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth.----------.--------------- <br /> Capacity.----------------- <br /> ---------Capacity.---------------- --TYPe-----------------------Material----------------- --------No. Compartments---------------------------------- <br /> Distance to nearest: Well------------------------------------------Foundation------- ---- -----------.Prop. Line--------------------------Gh� <br /> LEACHING LINE € ] No. of Lines---------------------------- Length of each line..---------------------- ----.Total Length---------------------------------------- <br /> 'D' Box------------Type Filter Material--------------------Depth Filter Material-------------------.-------------------------------- ........ <br /> Distance to nearest: Well----------------------------Foundation_-------------------_-----Property Line------------_---------------------� <br /> SEEPAGE PIT [ ] Depth---------- ----Diameter--.-----------------Number--------:----------------------- Rock Filled Yes.D No ❑ <br /> WaterTable Depth--------------------------- --------------------------- Rock Size------------------------------------------------ <br /> Distance to nearest: Well-------------------------------------------Foundation---------.----------------Prop. Line.--------------------------O <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------.Date---------- ------------------ ------- ---) <br /> Septic Tank (Specify Requirements)---.--- - ` 0 <br /> ------------------------------ <br /> ---' <br /> 4� <br /> Disposal Field [specify Requirements]-- ------ ---- ---------------- -------------- <br /> --------------------------- ----- ----------- --------- ------------------- ------------ ------- ----------------------:------------------------ ----------------------------------------- ----- ----------- ------D <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 agent'S3 <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 suct to Workman's Compensation laws of California." <br /> Signed------- > &Z6__ -----= 1' canes <br /> T r• �—'l , <br /> —_ ------- Title <br /> (If other than o�ner) <br /> FOR DEPARTMENT US LY <br /> APPLICATIQN ACCEPTED BY --- DATE. 1'"� r -0 <br /> - <br /> DIVISION OF LAND NUMBER-------- ---------- - --- . - ..--DATE ------------------ ---------- ------------- - <br /> ADDITIONALCOMMENTS------------------- --- ----------------------------------------------- ---------------------- --------------------------------------- __------ ----------------- <br /> ---------------------------------------------------------------------------------------------------------------'-:1'-------.....-..--------------------------_-------------------------------_-------------- <br /> ---- <br /> _.---__-_._..---0 <br /> -------------------------------------------------- <br /> ----------------- <br /> ------- <br /> --- ---------------------------------- ----------------------------- <br /> A_4L <br /> ----- <br /> J --- - <br /> ---------------- <br /> �� <br /> Final Inspection by: --- ----- Date r <br /> P Y --- - <br /> N 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV, 7/76 311 <br />