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FOR OFFICE USE: FOR OFFICE USE: <br /> 3 <br /> APPLICATION FOR SANITATION PERMIT <br /> ._... ..._. . Permit No.�.<..'_._.r�` <br /> {Complete in Triplicate) -------- <br /> •--•----------------- ---............................ � Date Issued <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 Ordin nce N . 549 and exi ting Rules and Regulations: <br /> JOB ADDRESS/1_0ATION � r�... + - - - - .. -----------CENSUS TRACT------------------------- <br /> Owner's Name... . .._.._ . . ----. :.--- <br /> ` .... .. .. ...--- • -...Phone..��a��.:-�� ..__...... <br /> Address �. . C1ty ------- -----zip--- --------- -- ----- - <br /> Contractor's Name-------------- �....��} License #.. G.. rj`,e L--- .Phone..�r .s�. C/ .... <br /> Installation will serve: Residence" Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------ ------------------------- •-.......... <br /> Number of living units:....-------Number of bedrooms.---7_..Garba e Grinder------------Lot Size....zdo .........:................ <br /> Water Supply: Public System and name ..1.A -------------•-------............----.------...........................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe KFiII'Matenal^.`.. If yes, type--------------- --- Az� <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 avoilabie within 200 feet,) 40 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size...r /j[5� ....._----------------_----.__..Liquid Depth... '�...-.---.....-.V <br /> Capacityl�D.�...- Typed! - .Mate-rial-.---�.----No. Compartments........:,�---------_-------V <br /> Distance to nearest. Well------- Foundation /..cr?.............Prop. Line---15.-. .... , <br /> LEACHING LINE No. of Lines.........................Length of each Total Length -------f,7 ------..ti.......----- <br /> / // •E <br /> 'D' Box....+./.__.._Type Filter Material�..�.. ... .-Depth Filter Material-.-----/.e�-...---------------------- <br /> S <br /> Distance to nearest: Well.---) __.._._....Foundation.....-- --....Property Line.....-..1- "-`�'...._...... <br /> SEEPAGE PIT O!j Depth_..rr�. ...Diameter.._33.........Number____ -_------------=--- Rock Filled Yeso No <br /> .r .i <br /> Water Table Depth---------4O-Q-------- ----------1..........Rock Size..-. - --_--------------------_-- <br /> Distance to nearest: Well.-.- /....- --....Foundation....G__O............_.Prop. Line.....�P-- .... � <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.............. ..._..............Date.------•--.•----. ----------------------------1 <br /> Septic Tank (Specify Requirements)..__................................................... ...................-------. <br /> Disposal Field (Specify Requirements)............... ----------•-•-----.---.-------------------.. <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 /> to become subloct t Worjwnan,s Oompensaticm laws of California." <br /> Signed. . --------------------- ----Owner <br /> BY................................�--� - .-- ............................_...Title...... ... - ------------------­---------------------------- <br /> (If <br /> ------------ --- <br /> (If other than ow4er) -0 <br /> Oft PARTME T USE ONLY <br /> APPLICATION ACCEPTED BY............. -- --------------------- --------DATE . I ..77--------._.. <br /> DIVISION OF LAND NUMBER........................ ...__-_.....-.--.DATE..---.-.-.----.------..-,. <br /> ADDITIONAL COMMENTS- ........ •........._ ---•---------------- ------ - -- ---------- <br /> ._------------------------------------------------------- ---- ---- ------------------------------------------------------------------.------------ ---...----------...- ---------- ---- ....... <br /> ---------------------------------------------------- ----------- ---------------------------------- ------------------------------------------•----------------------------- -------------------___--- <br /> ----------------------------------- <br /> --------------------•-----................ ......... <br /> Final Inspection b -------Dafen z.L ... . ...----_------- -- ---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M <br />