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FOR OFFICE USE: � FOR OFFICE USE: <br /> _ '� APPLICATION FOR SANITATION PERMIT � <br /> ---------------------------" <br /> (Complete in Triplicate) Permit No._�7"_ : ___-__ <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------------ -------.__------------------------------------------------- "ac_-�7 ENS TRACT___-___ <br /> Owner's Name.--- -- -------- G2G ------ ----------- --------------------------------------- ----- -------------Phone--------------------------------- <br /> lix <br /> Address--------- - - - ------ --------- --------- -----------------------------------------city ------- --------------------zi ------------------------ <br /> Contractor's Name ---- -- --- -," ------------------------------_License # 0 / Phone_ /D4 ___ 0 <br /> Q <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> otel ❑ Other--------------------------------------------- <br /> Number of living units:-----/--------Number of be ooms-_-._ garbage Grinder____________Lot Size____�_�. __l__ -1D <br /> Water Supply: Public System and name-------- -----------------------------------------------------------------------------------------Private El <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ J Size--------------------------------------------.--------------Liquid Depth--------------------------- <br /> Capacity------ <br /> _-___.________.______Capacity------ --------------Type-----------------------Material-----------------------------No. Compartments---------------------------------- <br /> Distance to nearest: Well--------- --------------------------------'Foundation--------------------------Prop. Line__________________________. <br /> LEACHING LINE [ J No. of Lines-------------------_---------Length of each line_------------------------------Total Length -_________-_______________________ <br /> 'D' Box__________Type Filter Material--------------------Depth Filter Material---------------------------------------------------------------- __ <br /> Distance to nearest: Well_-__________._________-Foundation_________________________Property Line ---------------11.3 <br /> SEEPAGE PIT ( ] Depth-----------.----Diameter------------ ------Number-------------------------------- Rock Filled Yes ❑ No OV <br /> WaterTable Depth---------------------=----------------------------------Rock Size---------------------------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line---------------------------- <br /> REPAIR/ADDITION <br /> ___________________-__-REPAIR/ADDITION (Prev. Sanitation Permit#_________-_______________________________--__-.Date_____._____________________________________) <br /> Septic Tank (Specify Requirements)---------- ----------------------------------------------------- --------- --- , <br /> 1L►�c'L <br /> Disposal Field(Specify Requirements) --- ---- -------------------- ,--- <br /> :�.� ----- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------- ---e--------------------------- - --- ------- ------------------- ------------------ <br /> - ------------------------ - -- - - <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 have prepared this application and that the work-'wiW 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 Ns-permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws,_of litonnia." <br /> Signed-------------------------------------------------------- ------- ------------------------------1 w- - .- <br /> By------ -------------- --------------------------------------- ==----------------------------------Title------------------------------------------------------------------------- <br /> (If other than owner) <br /> R PePA1qMENT USE OJN4LY <br /> APPLICATION ACCEPTED BYW----______--_DATE.____ --off'7_ _7_ --------------- <br /> DIVISION OF LAND NUMBER.--------- - --------------------------------------------- ----------------------------------DATE---- -------------------------- <br /> ADDITIONAL COMMENTS _--------------------------- -------------------------- <br /> ------------------------------ ---------------- - - -- --- � <br /> - <br /> 7------------- <br /> Final Inspection by - - <br /> ---------------------- ----------- Date------------------------------------------------- <br /> EH <br /> ___ _______ - -EH 13 24 ` SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 3M <br />