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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- (Completein Triplicate) Permit No.""7�Ty��_ f <br /> Date Issued.__sJ <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 describe f4 <br /> This application is made in pliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-__ -(/"�-A_,-__-- - - _____Phone.-- .NSUS TRACT <br /> ----.--� - --------- <br /> --- - ------ <br /> Owner's Nam -� - �. .--------�-����------- -------- - - -- <br /> Addressi".'L-� ------------- ----City---- ------------Zip-- <br /> . r <br /> Contractor's Nam License License # dS7 /"-"=""Phone_ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ ' <br /> Motel ❑ Other----------------- <br /> Number of living units------- ------Number of•bedrooms___7__-_Garbage Grinder.__'.._ -._-Lot Size--__.""l G[ '__________..___---_.___.-"-- <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 /> 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.) i <br /> NEW INSTALLATION: (No•septic tank or seepage pit permitted if public sewer is available within 200 feet,) It <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ["'}� 5ize___CU.- YJ _l Q__L _ ----_-----Liquid Depth__.-�"----------"-- <br /> / n <br /> Capacity �+`Q Qv Type ll Material [.0 -- ----- --No. Compartments------ ----------------------- <br /> Distance to nearest: Well-____t__ Ui - ------------------------Foundation-----1©..............Prop. Line__ W--r <br /> ----------- <br /> ° f a <br /> LEACHING LINE [��No. of Lines.---. -------------_-----.Length of each line.""-" ___ ____---- --_""Total Length '_-------� .�` _1_---.- <br /> t D' Box -Type Filter Material__r_��_ t t�.a Depth Filter Materlal_____ ___r----_ <br /> I ------------------5 <br /> 0I ' t I <br /> � Distance to nearest: WelL,�__�- ________________Foundation------�.��___..........___.Property Line--3________.______________ <br /> ► � r i <br /> SEEPAGE PIT [..]' Depth_c;t---------- Diameter--------.------.----Number----------- - -.- --_--- Rock Filled Yes Qw' No ❑ <br /> # Water Table Depth---1--j-Ur --- ---f --- ------------------Rock',Siie ------------------------------------------- <br /> Distance <br /> ------- - =Distance to nearest: WeIL"-----�. --------------- ------Fouridatio`n_0-- ____- Prop. Line__•------------_-"---___ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------- "------__-"_.--__________-__.Date-------------_" ) <br /> Septic Tank (Specify Requirements). = = ------------------------------------------------------- ------`-- <br /> Disposal Field (Specify Req,uirements)----------------------_------------- ---- __ -- ----------------------------------------- <br /> i Xj..1 , r i <br /> 1 w :t tI <br /> -------------------------"'--5 '-tom.`F: <br /> ---- -----------------------------; ----------y---------,--------------------- ------------------------------------------------ - ------------------------------------- ----- <br /> r , " (Draw existing and required addition on reverse side) I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County , <br /> r <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 o k for which�thisJpermit,is issued, I shall not employ any person in such manner as <br /> to become subject orkman' Compensation,laws of California." <br /> Signed---------- ----- ---- ---- --- -- = :Owner -• __ <br /> ---- --------- <br /> �� _ <br /> BY : Z -- - ` `''Title C - <br /> (If other than owner) <br /> --l—FOR DEPARTMENT USE ONLY <br /> J .-G --------'�<- - - <br /> -------- -------------------- --- --DATE --- ------ <br /> APPLICATION ACCEPTED BY____�_______ <br /> DIVISION OF LAND NUMBER- ------------------------- -- DATE------------------ ' <br /> ADDITIONAL COMMENTS-------- t\. .i,,� .:� = ------------------------------------------�-----------------? <br /> ------------------------- <br /> ----------------- - ` <br /> - - -------------------- ----------------------------------- ------- <br /> --------------------------- <br /> Final Inspection by:---= - - - Date == -- - ------------ <br /> EH <br /> - 1 <br /> EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />