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FOR OFFICE USE. FOR- OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> {Complete in Triplicate) ...Permit Na.......... . ....... , <br /> --------------------------- <br /> -------------------- <br /> Date Issue& ..--7� <br /> ................ ..�........-.......... <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.......... CENSUS TRACT_----_------------..... <br /> Owner's Name. .f�..i�..;f-.....__.- ------------ ---...._----..._---------•----------:--- ----/__ <br /> P_hone._. <br /> Address - .. Ci Q C - = <br /> . city.- 669_--- _...zip- <br /> � - _ <br /> Contractor's Name__':'...-- .�.L.-...1 �1-. .�_G'... .--------- ------------------ - ---License #- � .'�- .-Phone <br /> ofiel Ont House ❑ Commercial ❑ Trailer Courts❑ <br /> Installation will serve: Residence Apartment House <br /> ......... ........................ j G` <br /> Number of living units: -.1..-.-------Number of bedrooms..__ .Garbage Grinder--.. -Lot Size......... .......................................... .. I <br /> Water Supply: Publie'System and name ----------- ----------------------------------- - - ---------------------•---•-----• --------------- ---- -----------------Private 1 <br /> Character of soil to a`depth of 3 feet: Sand ❑ Silt❑ Clay'❑ e Peat❑ Sandy Loom.❑ Clay Loam AV <br /> Hardpan ❑ Adobe ❑ Fill Material.. .._ .___ff yes, type........... ------- �-� <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etcamust 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 f/ <br /> [ I Size.... � -�:- <br /> /�� ���---�-- -�-v- � - .Liquid Depth.--= <br /> /"y Yp P�� �^ P <br /> q Capacity . _.. ... T epi . �Sj`.Material No. Com artments.. ------ <br /> ---- <br /> Distance to nearest: Well---- .- � '' '�Faundation. - -_._r7" <br /> -------- ----- Prop. <br /> eLine_-. ..........-- -- <br /> LEACHING LINE ( '] No, of Lines.._--------------------Length of each line_-�--�........ Total Length ..../.� r�_.- 1 + <br /> ] D' Box_t........Type Filter Material116 , v�'/I�Depth Filter Material------ ------------�.:........ ................. <br /> DistancEi to nearest: Well- - .Y'..--...Foundation._O. <br /> _7 Property Line -`3 = <br /> SEEPAGE PIT [ ] ' Depth. .. - ....iDiameter.....................Nurnbe _=. _----- Rock Filled;. Yes ❑ No � <br /> ` -- . <br /> _i,.Water Table Qepth--------------- --•------------'----------`.�'--=-•----.-.Rock Size......... .......-.........--•.............. � <br /> f <br /> Distance to nearest: Well---------------------------------- -- •...Foundation_- .........-_....Prop. Line --..-----.-. <br /> REPAIR/ADDITION (Prev. Sanitation Permit ................... ......t"{"-.Date__......:------------------ _-- --------- <br /> Septic Tank {Specify Requirements]- ..-.. t ------------_----------- ---- = -------- ----------- :.. ...... ........ <br /> Disposal Field [specify Requirementsl...:-..- I <br /> ---- -- -------------- `----- ..------------- ------ . -- --- _--------------- <br /> ----•--••------ •-- -- ------- ----- <br /> ------------------------ ------------------------- <br /> - -------...._------------- -------------- <br /> ' (Draw existing and required addition on reverse side[ { <br /> I hereby certify that I have prepared this applicatlb-n—and that the work-will be"clone' in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local HealthlDistrict, 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 /> tobecome subject f Wo man's Compensation laws of California." t <br /> s <br /> Sig ned------- - <br /> - .. ✓� -------- ------------------- --- Owner t <br /> By......................-. ---- ----- .. Title.......------- ...................... t <br /> (If other than owner) <br /> FOR DEPARtMENT USE ONLY t <br /> - _- ..- <br /> APPLICATION ACCEPTED BY... DATE ...-- -`� 7:. . ... <br /> k <br /> DIVISION OF LAND NUMBER._...-- - DATE.---....-- •--------- ................ <br /> ADDITIONAL COMMENTS. - `.: .::. ...:.. .... _ <br /> _ <br /> ----------------- -----------......__:_P_�.. ..M.. <br /> ----- ---------- ---- --- ------------- ---- . -------------------------------- ... -- ----- -- . .................. .................... r <br /> l <br /> --------------------- - -- - -­ ------- <br /> T <br /> ..---.......Final Inspection by D <br /> EH <br /> 13 24 ""''-y''-'`" - r&S 21677 REV. 7/76 3M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />