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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.70_........ <br /> ..----••--------------- ---------- ------ ----------- <br /> •••... .......... -"- This Permit Expires 1 Year From Date Issued Date IlssuedlQ.,3/._7.. <br /> Application is hereby made to-the San Joaquin Local Health District for a permit to construct and,insta11 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..... -----..CENSUS TRACT........ <br /> Owner's Name..... . ��- --.-`--------------- --- � �-:--- ---•--:-----.....--- ---- - ---„ --=-----.Phone.. - - •- <br /> .......- -�----- ----�e- <br /> . . . . <br /> Address... v G? City p---- <br /> Contractor's Name.....�� License #.-a1,7L�-,3.9 Phone--. ?.. �C�.... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> / Motel ❑ Other- ----- ----------------- <br /> Number of living units:...-..�!`._- '-Number of bedrooms.-....Garbage Grinder----........Lot Size-----4 .. <br /> Water Supply: Public System and name--- -- ------------------ ”--- -...--........... - ----"-- ....---•------•------ ---------L..... . --- --------------------PrivateX <br /> Character of soil to a depth of 3"feet:. Sando., 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 [ ] Size...:......... .. ........... ------Liquid Depth------------___........ <br /> : . <br /> Capacity Materia!' ... ............. .....No. <br /> Compartments---..... ------ <br /> Distance to nearest: Well----------------------- ------_.. --------Foundation..-----.-- - . Prop! Line <br /> ........._...........--.-- <br /> LEACHING LINE [ ] No. of Lines_............ . t <br /> -------••---,Length of each line................. •------ Total Length ...................____....... <br /> _... <br /> 'D' Box.--- ......Type Filter Material.... ...............Depth Filter Material--- <br /> ------------------------------•---------------.-------------- <br /> Distance,to nearest: Well------------------- ........Foundation-------_-----•---""-""-"-.Property Line—....-.._...... ................ •. <br /> SEEPAGE PIT " ` <br /> [ ] Depth.......... ......Diameter----------.........-Number....----------.-.•-------------- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth..................•-------------- ----------------------Rock Size._. ...- ---....__------- ----------....._ <br /> t z <br /> Distance to nearest: Well.__.---------- < ..---- ------Foundation--------------------------Prop. Line_--------...........---.- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_--------------------------------- - _------_--Date-......•--....-................................ <br /> ] <br /> ---------------- . ......... --------k <br /> Septic Tank (Specify Requirements)"-- ----- -------- -- ..--------.. a.-...... <br /> Disposal Field (Specify Requirements) G_� -> ...... ------ - - ---- -..... <br /> -----------------------....-............. .................... -------- <br /> ----- ------------------------------------------------------ <br /> {Draw existing and required addition on reverse side) f <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,D.istrict;:,H.ome.owner or licensed agents I <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 Deco _t'_t0­ <br /> a"sCompensation�.laws-of California." <br /> Sig --------------Own' <br /> Owner' - <br /> itl <br /> BY ---...- Te--e4-7 <br /> .. <br /> R <br /> E <br /> other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> (�V <br /> DIVISION OF LAND NUMBER ___7' <br /> . ........................... ................................=.......................DATE.... ------- <br /> ADDITIONALCOMMENTS......................_--------------------------------------------------- ----......-- ------. ---.....-.... <br /> -------------------- ------------ - ' . --:--------------------:.:._:.._-•------- ---------------------------- --• _---------• ---------- ..... <br /> ---• --------------------------~="_ - . <br /> ----- --------- ----------- ^~�,.. <br /> Final Inspec>'ion by: ....... ..... ... 1 f . . - -:� ... <br /> ...Date:..- <br /> ^-.... - :� z� <br /> EH 13 24 ^R1¢jjj <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �-_.w-.�.-- <br /> F&S.2]67J E6 3M <br />