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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT - <br /> (Complete in Triplicate) Permit <br /> ------------- ---- ----------------------- -------------- <br /> --- - ------------------ This Permit Expires 1 Year From Date Issued Date <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 withlCounty,Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 6._5&O' <br /> Y---------- CENSUS-T-RACT.=- - - = <br /> Owner's Name 1 �- - -- -------- - hone_---- --------------------- -------- <br /> Address ---------- ----- <br /> ;:Z <br /> City- ------- --Zi <br /> ntractor's Name--'---� '-.. - ----J ---------------------License # Z Phone <br /> Installation-will. serve: Reside ce ❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> �... .T... ! -Motel ❑ Otherz _- «� � <br /> Number of living <br /> t units-----------------Number of bedrooms-.- --,---.Garbage Grinder---------—Lot Size--------- _r--------- <br /> ----------- __ <br /> Water <br /> i <br /> Supply: Public System and name-------------- ----------------------------------------- -------- - Private <br /> _ ------------------------- ------------------ <br /> Character of.soikto a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ ; Peat❑ Sandy Loam [� Clay Loam ❑ �Q <br /> Hard an s " <br /> P ❑'T Adobe ❑ � Fill-Material_ ---------If yes, tYPe------------'--- Q <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------------------- <br /> -------- Liquid Depth---------------_ <br /> t Capacity-^ ' 'TYPe =-------=--- Material..................... t._9Vo. Compartments. <br /> ---------------- <br /> Distance-t6 nearest:.Welf_ ------------------------------__'___Foundation,.1-z.--_„----------------Prop. Line--:------------------------. <br /> LEACHING LINE ; <br /> [ l No. of.Lii-tes'--=-------�--•-- - -.Length of each lino-----------------------------._.Total Length.- --------­ .:------------------- <br /> 'D' Box------------T -p-6-FUe—r Material--------------------Depth Filter Mater.' <br /> tDistance to nearest: 1NI- _ <br /> el ----- ----------------------------------- _ <br /> Foundation----.----_---_____------:---Property Line__.___ ---.--.--___----- --- <br /> SEEPAGE PIT [ ] ,Depth_ _______________Diameter-------.-..------___Number-----------------.-__________.-- Rock Filled Yes ❑ No <br /> r Water Table$DeptFi------------` Roc Size---------------------------=------------------- <br /> ----------- ----- -- -- <br /> Distance to nearest: Well'----------------------- ------------------ Foundation--------------------------Prop. Line-------------------.---- - <br /> REPAIR/ADDITION {Prey. Sanitation Permit#---...................---------------------°._----.Date.____------_-------------------------- <br /> Septic <br /> -----_______-_---.- .--Septic Tank (Specify Requirements)-_1 ----=--- --------- ----------- --------------- --------------------------------------------- <br /> ---------------------------------------------- ------- <br /> _ <br /> Disposal Field (Specify Require rrits) _LL---'- -------fit/----- <br /> ---- <br /> =` <br /> 17 <br /> --- - <br /> '” <br /> - -------- --- ---- ---- <br /> 1 ) ' _ <br /> ' -------------------------------------------------------------------- <br /> i {Driaw'existing and reiaui�ed 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 /> Ordinarices,. 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 subject to Workman's .Compensation laws of California." <br /> Signed---------------------------- -------'-------- = Owner <br /> ___r_-- ._ __- <br /> BY - Title - 11--------------- - ----- ---------- <br /> j (If other'tan owner) ' <br /> f FOR DEPARTMENT USE ONLY <br /> • <br /> APPLICATION ACCEPTED BY----- - -- --- -------------- --------------DATE.--L� <br /> OF LAND NU T_ - ----------------- --------------------------------------------- --- DATE- --- ----- ----- ------------------------------- <br /> DIVISION d <br /> ADDITIONAL COMMENTS---------- ---- --- --------------------------- <br /> ---------------------------------- <br /> ------------------------- +~ = <br /> t <br /> ----------------------------------- ----- --------------------- ---- <br /> Final <br /> by: r ----------- <br /> pate_ . <br /> Finsp ection b ` <br /> EH 13 24 [ SAN JO QUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> inal <br />