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FOR OFFICE USE: v- FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------- ---------------------------------------- Permit No.---- - <br /> (Complete in Triplicate) <br /> ---------- ------------- --------------------- ------ - ! <br /> Date Issued- -t`�/Z.1_. <br /> -------------------------------------.------------------- This Permit Expires 1 Year From Date Issued <br /> i< <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described.+r <br /> This application is made in compliance with County Ordinance.No. 549 and existing Rules and Regulations: <br /> .. �. <br /> JOB ADDRESS/LOCATIO4'.S` -"• r =---CENSUS TRACT -------- ,....-- <br /> Owner's Name f'G� 1 -------- ---- ------------ ------------------- <br /> -- - <br /> Phone <br /> ------ w \ <br /> Address_:__'... , ----- - --- - � ---- - �''�'---City --4)4 <br /> - - --- -t--------�- --Zip---� �.�'.'� •----� <br /> 3 F- D v - <br /> Contrac#or s Name-- -- -- --- ----- License � Phone - <br /> Installation will-serve: r Residence Apartment House.❑. Commercial ❑ Trailer Court❑ <br /> yy Nu be' .. .�..... ..w..- .. .. . __ ......e Motel ❑...: Other --- -= ----------- <br /> '------------- ---=- <br /> r of,liv,ing units:__.'._! _- Nurriber,of bedrooms'_-_-__.---Garbage Grinder--- Size------.- � ' --------------------- <br /> Water Supply: Public System and name-.---'--------------------•-=-- ---:----- :- :--.-- =- at <br /> Priv e . <br /> Character of soil to a depth`of,3 feet: Sand F Silt ❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam E] <br /> 1 Hardpan E]".' Adobe.❑ Fill Materia ---------- yes, type----------------------------- f <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�'sep'-f c tank�:or -seepage .pit permitted if public sewer is available within 200 feet,} <br /> g . . .. ._ i - <br /> PACKAGE TREATMENT .[..],.* SEPTIC TANK [;•] • � '�' Size________________-_-__.-----------.--'------- ----t-- L,quid Depth , ------- <br /> � <br /> �. ... . . .:Capacity :........ = TYpe== f :_.Material------ = = ,..__.k_.No.•Compartments -------- . --F---- <br /> -Distance to nearest: Well::- j--==--------- °Foundation-_---__,=--___, -----------Prop. Line-;_--------------___--- <br /> . �. �t - <br /> LEACHING LINE [ ] No. of Lines-------------.:-------- .Length of each-line-- ----:-----`--_-- ---- Total:,,Length.;-.-------------------------------- -- 2r <br /> _� <br /> D' Box------------Type•_Filter Materia! -. Depth Filter Material s___.._. __ .- <br /> 'x I t ------ . t _ ------------ <br /> ! Distances to nearest. Well.; """•�'1 ounlatioTi�"- -_s_ - Property Line_ . <br /> SEEPAGE PIT [ ] Depth---.'-----------Diameter------------ -__.Number- ____________________ Rock Filled Yes ❑ No ❑ <br /> y Water Table Depth --- - - - Rock Size--- - --------- -------------- <br /> ,...._,..e.. F <br /> - ------..Prop. Line <br /> Disf6in"to nearest Well ------------ ----------------- oundation____-- <br /> f REPAIR/ADDITION-(PrEV Sanitation Permit#....-": ------ .--------------=---------------Date--------------------------:--- ----_--------1 <br /> Septic Tank (Specify Requirements}-- --------------------- ------------_ ---------------------- ------------ -------- <br /> Disposal Field (Specif Requireme s}-- C is , <br /> ---------------- <br /> , _ _-_ <br /> . <br /> - ---------------------- ---- --------------------------------- - -- ------ ------------ ---------:-------- <br /> -(Draw existingand required addition on reverse side) <br /> I hereby certify that l 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 mannerkas <br /> to become subject to Workman's Com nation. laws lifornia." . <br /> I Signed------- -----------'------------------ -- " - ner <br /> Ow <br /> BY---------------------- ------------------------ -- ...Title--- ---- ------ =--.------------------------ --- ---------------------- <br /> - <br /> ' (If­other than owner) ; <br /> FOR DEP TMENT USE ONLY , <br /> APPLICATION ACCEPTED -I - - -- -- __ DATE_ <br /> DIVISIONOF LAND NUMBER ----'-- -- - --- ---------- --- ----DATE-- ------------- ------------------------ ----°----------- <br /> --;-- <br /> - -ADDITIONAL COMMENTS - --- ------------------------ -- -----------------:---- -=•------------ ----------- :------ --------------------------------- - ----------------- ------------------ <br /> _. - ----------------- <br /> -----------r - --------- ----------- <br /> --------------------- -- <br /> Final Inspection by---=--------- - Date' <br /> - ---------- <br /> - -- - ------------------- - <br /> EH 13 24` SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />