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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.. <br /> Date Issued_5`._ ._ 9 <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/LOCATI N 5' 7....----- ��f / `4------------------- - CENSUS TRACT-------------------------------- <br /> -----------Owner s Name ---------------------- --------------------------Phone------ ---:->--- ----------- <br /> Xd <br /> Address-----:--------- ------ '. City Zip 7 <br /> �� i' Q� d <br /> Contractor's Name--------- <br /> Installation <br /> - = ------,� -----------------------C-- 28x z-E, <br /> License # .3 ----Phone------------------- <br /> Installation will serve: Residence ❑ Apartment House.F), Commercial ❑ Trailer Court ❑ <br /> t R. Motel ❑ Other--- ` ``�-- zrGA �. <br /> Number of living units:_.._____.___Num ber of bedrooms-----7--__Garbage Grinder------------Lot Size----------------------:--------------------------------- <br /> Water <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 /> - <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.) N <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------------------------------------__—'J.__'__.__-_-____Liquid Depth --------------- <br /> f F <br /> Capac�Y -Type ------- ---- ---------Material`-------------------------No. Compartments------- - ------`------------------ <br /> ` 'Distance to nearest:.Well-----------------------------------------!- Foundation.,.: ---- -----------.Prop. Line---------------------------. .11 <br /> -- - - --.Length. __ - <br /> of each .lina.< ----- -- ...' :.. Total Length --------------------- <br /> LEACHING LINE [•] No, of Lines____,_____._____ _________________ L� <br /> 'D' Box,-_.__--------Type Filter Material---------------------Depth Filter Material.---------- --------------------------------:------- <br /> Distance;to nearest: Well_:___.________.___._.____Foundat.ion_________________°_r_______..Property Line <br /> - <br /> SEEPAGE PIT [ ] Depth----------------Diameter..___:_____::.____ .Number______iw F-_______.____*__ - Rock Filler) Yes E] No-10 <br /> Water Table Depth------------ <br /> -----------------------------------------------Rock Size'---------------------------------------- ------ <br /> Distance to nearest:-Well_ ---- ~� <br /> -� - ---- --------------- ----Foundation---------= -------------Prop, Line----------------- <br /> { .fr A N. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------`-- _=----- -----:- ------Date------------------------------------_-----------M <br /> � y .a� <br /> SepticTank (Specify Requirements) ,---'------------------------------=--------------------=------- ,. -------------------=------------=-=----------- ---------------------- <br /> ------- <br /> -- <br /> Disposal Field (Specify Requirements)_.._SGS- I--------�✓---------- ---- ------ ----- --- - -- -------------------- --------------- -- -- T <br /> 01 <br /> -----------------------------------------------------=- I---------------------- ---------------- ------------------------------- --------------------------- ------------------------------ <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 iri'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 /> E <br /> Signed--------- ----------=-----=-- ----: ---------------- - -- 'Owner <br /> By-= ----------------------- ' Title <br /> U <br /> : (If other than owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED; BY-=-- -- --- ----------- --------------- --- ----------------DATE.---- !77- --G - <br /> DIVISION OF LAND NUMBER--------------`---------------------------- --- -------------------------------------- -------------- <br /> ADDITIONAL <br /> ------------ADDITIONAL COMMENTS---------- ----------------------------------------------------------------------------------------------------------------------------- -------- ----------------- <br /> ------------------------------ <br /> ------------------------------------ --------------------- ----------- --------;------------------------------------------- -------------------.---- -------- ------------ ------------------------- <br /> ) = ----- - ----------- <br /> ,-F <br /> - <br /> Final Inspection by-------{ — _ -- --------------Date d ----- -------------- <br /> / �- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />