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1 it <br /> FOR--OFFICE USE: FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT F <br /> "7 _1d3� <br /> - r . <br /> (Complete in Triplicate) Perr li*1o..._____________ ____ <br /> --------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued--------------------- Uate Issued_.«_�_ ___� <br /> ,j <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 existi�Rld Regulations: <br /> JOB ADDRESS/L T Ti0 � <br /> - -- - -- ------------ --- --------------------------------------------------CENSUS TRACT ------r---- ---- ----- <br /> Owner's Name ` --------------------- ---Phone__ l� `� i <br /> Address-- _�` / F._ .. �-----------------City - --------- -- ---------------zip -- - -- --- - <br /> Contractor's Name-- ..__ License #- -- --.-Phone_ G/�_-- <br /> ----- -- --- ---------_------- <br /> Installation will serve, Residence 9?;01 Apartment.House ❑ Commercial ❑ Trailer Court ❑ <br /> ;• a Motel ❑ Other-- --_- --- - --------------- <br /> ------ <br /> - <br /> - - -------------------------- <br /> .- .- � .. � <br /> Number of living units-----/ <br /> Water <br /> of bedrooms __.___.Gar age Grindex____._______Lot Size________________--_______.__.__..___.__.__._.__;._,___F_. <br /> Water Supply: Public System and name---_--------------1-- ------------------------ --- ------------------------------------------------------------------P(ivate� <br /> .. �Y <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 seeps a pit permitted if public sewer is available within 200 feet,) <br /> r ' <br /> PACKAGE TREATMENT -SEPTIC ` <br /> [ ] SEPTIC TANK [ Size ____ ._ _.___ .__ __ ___ ___________Liquid Depth.___._._______`________ <br /> Capacit _. '-;Typ !� _. ___ _ _.__Material4. • ----- <br /> ---------No. Compartments------------- ''_f <br /> Distance o fne6Line_Z�___. _ __.__._ <br /> LEACHING LINE [ No. of Lines.__ :_.__..Length of each line Q_rz�Q__�Q________-Total Length..__/a_�_____- <br /> - ,,gy�pp � � <br /> - .`D' Box .Type Filter Material_�^__e P1_ __.Depth Filter Material___ ---------------------- <br /> R <br /> - <br /> [ Distance to nearest: Well-- fid� _ FFoundation__a�________________-Property Line? ___ ____.___ <br /> SEEPAGE PIT Depth._O '_;1T:----Did meter__ __ _________ __ __.____.________ sP Rock Filled Yes ;-------- <br /> No <br /> _ ------------------- ---------------- <br /> umber _ <br /> Water Table Depth ______ _ d r Rock Size__ _ �_--r..__ f <br /> Distance to nearest:'Well_____ -----------------------:Foundation---- _ _._________.Prop. Line__7 ________________ <br /> REPAIR/ADDITION•(Prevr.Sanitation Permit#-`--'--�----__......................_..............Date_-----.---------_---------------___---_---------- <br /> ) 1 <br /> Septic Tank {specify Requirements)------------------------ <br /> ---------------- --------------------------------- ----------------------- ------=---ti------ ' <br /> f <br /> Disposal Field (Specify.Requ.iremtints)-- -------------------- -------------------------- --------------------------------------------------- 4------- i <br /> -------------------------------- ----- -- --- = ---------------------------------=--------------------------------------=---------------------------------------------------------------- --------------------- <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 /> 6 � . <br /> '.1 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 beco jec! to W an's om ensation laws of.California.'� <br /> Signed >...... --V <br /> ---- Owner <br /> r - F --- Title - ------------------------------------------------------ <br /> By- <br /> ----------- --- -------- --(If other than owner) ! <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. B 4 <br /> �- - ---- . DATE._�.Z-_ ' °-------------- <br /> DIVISION OF LAND NUMBER----------------- -------__-----------.--.DATE--,------------------. - <br /> '-ADDITIONAL COMMENTS - - -------------------------------------------------------- -------------------------- -------------------------------- -------------------------------------- <br /> ----=-----------------------=---------------------------- --- ----- --------- -------- -------------- ----------------- ----- --- -----=---------------------------------------------------------------- --------- <br /> R -------------------- ------- --- ----------------- <br /> _ ------------------- <br /> -------- --- - --------------- - ------ -= - <br /> Final Inspecfion�bY=------------------- •-------- -- = --- - -- - - Date --- <br /> �'----- --- - ----'-1- <br /> EH 13 24 SAN JOAQUIN LOCAL HELTH DISTRICT F&5 21677 REV. 7/76 3M <br />