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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- <br /> (Complete in Triplicate) Permit No. .._,�...... <br /> •-------------------- ---------- ................. <br /> Date Issued... .......... <br /> ........... .....----•--. ------- - ...------.......-- This Permit Expires 1 Year From Date Issued <br /> i <br /> Application is hereby made to.the San Joaquin Local Health Di'strict for a permit to construct and install the work herein described. <br /> This application is made in_compliance with County Ordinonce,No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.... °° U1 ...t- 1 x _ SUS TRACT--------------- ....... <br /> -()+ <br /> ' "-.�:. , ry .. <br /> Owners Name .-..- ... ..Phone--- •--------- ............. <br /> --- ------- <br /> Address - - Y;P ;CitY' � - '�1 :------------ ---- - --zip--- �s..�f ------ <br /> J-2 _ <br /> Contractor's Name........._ j <br /> e7 <br /> Lit # Phone... <br />! insfiallation well serve: " Residence (}Apartment House ❑ Commercial ❑ Toiler Court ❑ <br /> / Motel ❑ Other-------- ---------- ------------------------- <br /> s. ' Number of living units:........1-------Number of bedrooms..... .._..Garbage Grinder..--1-7- of Size_---- _-------------- <br /> Water Supply: Rublic-System and name.. . ` ------------------------- --------- ------...----.Private 0 <br /> Character of soil to a'depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam [Clay Loam ❑ <br /> ❑ Adobe ❑ Fill Material.. .... ....If yes, type................................ <br /> (Plot plan, showing size of lot, location f system in relation to wells, buildings, etc, must be placed on reverse side.) W <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] a <br /> PACKAGE TREATMENT [ } SEPTIC TANK _ Liquid Depth_..................... <br /> � ] Size- - ------- ---------------------�---------...... <br /> Capacity... 6Iia...Type--- 2-i 2 rMaterial-----CQ}�4--=�Ao. Compartments.---- -- — - -----f ----� <br /> Distance to nearest: Well' C�E7................:....Foundation.......Q..........Prop. Line...l®�' i <br /> LEACHING LINE. [ ] No. of Lines'....3.................. _ <br /> Length of each line ......IYV----------- --- Total Length .... ..:.-.- <br /> 3 ....-....... <br /> D' Box--:`-(......T_ype..Filter Material—:.20c,(/.Depth Filter_Materialr:...� �: -...---�--- ^-•_- `= ` .:r _--- <br /> � � Distance to nearest: We ........O=Q_ ,......Foundation..... .Q.............Property Line.-:. -...-�..- I <br /> f.ry <br /> SEEPAGE PIT [ } De th_.__ _ Diameter Number........ ----------------- Rock Filled Yes No <br /> p 1, . �,, ti <br /> Water Table Depth............ ��-_... <br /> Q ...............--------•-------Rock Size... -2-q?----------------------------- <br /> -- � <br /> Distance to nearest: Well_-_-_..400.............. ..Foundation.......(0_ _--.__- Prop, Line.... <br /> i REPAIR/ADDITION (Prev. Sanitation Permit#...--.--_..._•-----•-----".......... ...............Date---.----:-----....... ----------._...--------- <br /> ] <br /> Septic Tank (Specify Requirements)------ ------------• ......... ----- --------- -------- <br /> Disposal Field (Specify Requirements).......-----• - -.-f_ -........ ---- - - ..--_- •-------------------------------------- ............. . <br /> z` " <br /> ---------------- -------- ....... <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 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 /> t to become subject Wo a Co cation laws,"of ,California." <br /> Signed-•-..-- -.:,- : - --Owner <br /> 3 <br /> . <br /> BY------ - <br /> ------------- ----------- -•-------------- - ..... ...Title......... - ---------------------- -- - .............. --------- <br /> , <br /> (If other than owner) N `, <br /> FOR EPAR Y � T USE OIjLY <br /> APPLICATION ACCEPTED BY."........ . ./Le....... :.. �r d?. '--------- ---------------------------..DATE <br /> DIVISION OF LAND NUMBERG. ..� -.�I ..._........... ` <br /> E .----------_ _ <br /> .............------ ---•-- - - ----- ...-----.�.......... ------------- ---....----DATE.--- ------------ ----.......... -...-... <br /> ADDITIONAL <br /> r . <br /> COMMENTS....-- .. ............ -•- - " ........._.. ------- ....... <br /> -------- - ..... ............... ---------­----- - -------------- ..... .------------ <br /> ------------- <br /> . <br /> ---------------- ---------- f ........ ---.._ ..-- <br /> t Inspection by---- - --- ------ ------- -- ...Dote... r. y <br /> Final <br /> -EH t3 24 SAN JOAQ ' N�L`OCAL HEALTH DISTRICT <br /> F&S 21677 REV. 7/76 3M" <br /> 5 <br />