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FQ_R OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> = ----..H a.:��y.-- •-- <br /> (Complete in Triplicate) Permit N <br /> Date Issued........ T <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 compli ce with County Ordinance No. 549 and existing Rules and Regulations: <br /> I p ,a <br /> JOB ADDRESS/LOCATION.... . . ---- ... h. fSQ.T..- ------- -------------CENSUS TRACT..------------. <br /> Owner's Name ffd------------L&QAl---- -- --- - --------- ....................Phone.........---------- <br /> Address.......... ....... A. ! = ----- <br /> - - -- Cit .....zi --- <br /> Contractor's Name...r- - 02 /J UjLicense #._// 4.�C6._ Phone_?J? .-._ W--- .. <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------ ---------- ----------- .......... <br /> Number of living units;.....1----------Number of bedrooms., -- - Garbage Grinder...-----....Lot Size.--��s�.�...... . .......... . <br /> Water Supply: Public System and name-------- ----------------- ------ ... . ......... -------- ---------­---- ----........-----Private � <br /> Character of soil to a depth of 3 feet: Sand Silt F] Clay ❑ Peat ❑ Sandy Loam LR[ Clay Loam El !` <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 OC] size..._/G�'U......-_ rA-1 ............. ..........Liquid Depth... 6_- <br /> Capacity/6.00-4.41-..Type.,P0_ : ' 'ksT.Material_. ( a�T'L.-...No. Compartments.-.-I------------------------ <br /> Distance to nearest: Well......M!.............................Foundation....ta-` ..._. ._ _..Prop. Line_.�0..�............�1m <br /> LEACHING LINE [ ] No. of Lines...-3......................Length of each line.--Z&.............. g _110 <br /> ---.... Total Length ------ - ------------------ <br /> tr <br /> D' Box....1......Type Filter Material...i{o_CK.......Depth Filter Material...-if$.--------_--------------•-------------.---------- <br /> j l 1 <br /> Distance to nearest: Well---- ..........- pert Line..--.Ei_•-------------- <br /> ......Foundation- -- � -----------------Property I SEEPAGE PIT [ ] Depth................Diameter....--------___-----Number----------------...._------._.- Rock Filled Yes ❑ NWater Table Depth------------------•----- -----------• -------Rock Size...--------_------------- _----••----------- <br /> Distance to nearest: Well........................................ Foundation----------__--- ....__..Prop. Line..--.------------..... <br /> REPAIR/ADDITION (Prev. Sanitatibn Permit#----------------------------------- ---------------Date.----------.-------------- -------------------) <br /> Septic Tank [Specify Requirements].--- .... -• - -- --_-----•--- --------------- ------------- <br /> Disposal Field (Specify Requirements)---------------------- ----- -------------------- <br /> ­.___1___­.............. ------------ ----------- ------------ ------------ --------------------------------- --- ----------- ------------------ ----------------- <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 subject to Workman's Compensation laws of California." <br /> Signed..... .............. .. ....... <br /> f---- - ------ --.----.._...........--------- ----....Owner <br /> BY. .... 7 � Title. r ... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED DATE dc,>_`...../ __--- - ------ ---_-- <br /> DIVISION OF LAND NUMBER......--- __ __ DATE -------------•--.....-: .... . --...----- <br /> ADDITIONAL COMMENTS......... � ?r't.' �1. l�Yl <br /> ----••-•----- •---- --------- ------ - -----...-------------•------------------------------------------------- --------------------------- - ---- ...... <br /> .... ....... <br /> Final Inspection by:......., . <br /> ......................... ....... --- --- •............ ---------.Date.----- <br /> EH 1324 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7/76 3M <br />