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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .. ......--- __. _. ...1..::.:_.�,.. <br /> (Complete it Triplicate) Permit No, <br /> Date Issued......�.,cl..:....�.'.<i' <br /> .........................-. - - _. ...... This Permit Expires 1 Year From Date Issued <br /> kpplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> 'his application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> -2,`'&. �js �W ear moo' s 1 <br /> JOB ADDRESS/LOCATION.......... ....... . .....................................�'..._.�..�. ....��.------. ------CENSUS TRACT..- -- ......----. .......... <br /> 2.:........... -------------------- -- _....._..... Phone................. _ <br /> .......... ... ...Dwner's Name.... .. .. .. ........._..S014Q..... . <br /> Address.......... .... ....I ) ................. 421a'jru kt?.: i.�°+vE�(' <br /> .. t . <br /> k : _.......... ... City..... ..... .. ........ ..._..........Zip------ ....................... <br /> :ontractor's Name........ .. . ..........jQVkR97..................--... . ......... ......_........License #... . .... ` .Phone...9. !.`+_.6..y.9_.. ....... <br /> nstallation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other....GAZ.0..... ......................... "CC <br /> 4umber of living units:................Number of bedrooms......... . Garbage Grinder............Lot Size.............. .................. ._. ..t <br /> e <br /> Water Supply: Public System and name.. .... .................................. .............................................. .._ _._.. ------..........Private � <br /> ':haracter 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, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) < <br /> t <br /> JEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [A Size.......) ?. _....`�A'............................Liquid Depth... . ................. <br /> Capacity...l qcv .........Type?7?--C.Wg.�. ......Material....famxh—.- ...No. Compartments......__.Z.................... <br /> Distance to nearest: Well........... .....................Foundation.......1.0. ...... .. ...Prop. Line........ ........... <br /> LEACHING LINE No. of Lines ............1............ g _-... U g <br /> ..Length of each line.. _. �._........_._-..... Total Length . QUA......................... <br /> 'D' Box...........Type Filter Material� Depth Filter Material.......I�R........ . ... ............. .......................� <br /> Distance to nearest: Well....3.5'...............Foundation._.____-_.oaf?.`-_-.........Property Line....... �................ <br /> -EEPAGE PIT ( ] Depth.......... .....Diameter....................Number................................ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth. ).3, ...X.............................Rock Size.. Z .__ _ ----- ------- <br /> Distance to nearest: Well...........................................Foundation... _ _ Prop. Line................. <br /> ,EPAIR/ADDITION (Prev. Sanitation Permit#................................... ...............Date.....---_... ... ..___.... . . .__._.) <br /> Septic Tank (Specify Requirements)------ --------------------------------- -------------------- <br /> Disposal Field (Specify Requirements)....... .............. - - -_ - - -- <br /> ........................................................................................ ................................ ...................................... ... -- . . .. _.... . <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 /> ignature certifies the following: <br /> '1 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 b[e to or an's Cpm ensation laws of California." <br /> ii ned ..........Owner <br /> By......... ....... ............. - ---..... __ Title... .------........ -- ........._. .-- . . -----...._..... <br /> (If other than owner) <br /> FOR DEPARTMENT USE-ONLY <br /> APPLICATION ACCEPTED BY..._._. .:� � r� '. _....... .DATE .....r <br /> , �-' '�;............. ......_...... <br /> . ........ . .......... .. ..... Gs� <br /> DIVISION OF LAND NUMBER,,........ .... ........................ . •----- -_.._.. DATE............................... <br /> ADDITIONAL COMMENTS. <br /> .. <br /> ............................ ......... ........................ . ... .................................................................................................................... .... ...... .. . <br /> ..-•------------•...... ... ........ ..............._ . . ._.. ... ................................---........---.------........................................... ---..._...... .._._......--.........I........ <br /> .......................................... �.. .... ...............................------------...----._... ............................. ......... ........... 1 ....... ..... .. .......... <br /> Final Inspection b � ------------------------ ........................................................Date <br /> ..., - .-- :,,... .......... .._.. <br /> FH 11 04 c ani intim ani i r)r'Al HFAI TH M.cTRIC'T �Fas 21677 REV. 7/76 3M <br />