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FOR OFFICE USE: .. '" FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....................... (Complete in Triplicate) Permit No... �'a 7­-----------------------­1........ ....... <br /> .. Date lssued.. ..._�_-?� <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 complioncel+vith County Ordinance.No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION......../i ' Y7 ....... ----------.CENSUS TRACT-----..--- --------- . . <br /> Owner's czName......... --Cy.z[�L- Phone........ <br /> Address_...------.7.Y_ -- � --- ---... ...----- -..City----- ------ ----•------- - -------Zip------- -- <br /> Contractor's Name....... .... ... . License #-- � .I_......-Phone... ilOf��A,�------ <br /> ------------- ---------- <br /> Installation will serve: Residence Apartment House E] Commercial E] Trailer Court CJ <br /> tel ❑ Other----- .......... ---------------- ••-- <br /> Number of living units:_......1-_-.Number of bedrooms.. _Garbage Grinder------------Lot Size-/-r!.a . .��-. :--- .--...... .. <br /> Water Supply: Public System Gond name 0--------------- ...................I......._-._.....------------- .-. --Private <br /> Character of soil to a depth <br /> of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> S Hardpan ❑ Adobe-.❑_Fil.l-Mater-ial:: ._ -.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.) ti <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) pQ <br /> o <br /> PACKAGE TREATMENT ( ) SEPTIC TANK .. *_A. 4,0-------------=--- ----Liquid Depth....-...- <br /> Capacity... O.C2.Type--,.-,f----.......Material.--• ..'.-------:No. Compartments--- --= -------------------------� <br /> Distance to nearest: Well.-:----- ...... ........Foundation...1.0 ._.- ....... Prop. Line.............._....-. <br /> LEACHING LINE No. of Lines .......... ... .._--- -.. . <br /> ( � p"� . Length of each line....... _1:5k.............. Total Length j-zr------..._.....--.._-..-- <br /> 'D' Box..../.....Type Filter Material.--- Depth. Filter Material.. ./-��----... ------------------------------------ <br /> ----- <br /> Distance to nearest: Well-..._........:....._--..- Foundation........`. Q..-..; -Property Line ---...-/...C .-..----------------. <br /> SEEPAGE PIT [ ) Depth--- — ' Rock Filled Yes 4 No EJWater Table Depth.-_-------------•------------ -------_... .....-----.Rock Size.._/. --- ------ <br /> Distance to nearest: Well.-----/67 Q---------------- ---- =_Foundation_. .....Prop. Line _/V---------- -.----- <br /> RIEPAIR/ADDITION {Prey. Sanitation Permit#------------------------- ..........Date....:-........... ) I <br /> Septic Tank (Specify Requirements)-------- ----------- --- ----------------- <br /> Disposal Field (Specify Requirements).................•.. -- F ------------------ ............... I <br /> ----------- --- ------- - ---------•------- <br /> 1 3 ........... ......................... <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: F I <br /> "I certify that in the performance of thI 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-.._... # - ------------ Owner <br /> C - - L ...........Title------ ----------------- -------- ------ ------ ........... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- - W--...._. DATE . <br /> DIVISION OF LAND NUMBER.-------- - '_....._. . .DATE. <br /> ADDITIONAL COMMENTS.. .......... ... I <br /> . [ ----------- - ------------ ............ .......... <br /> ..........._................... .......... <br /> : t <br /> ------------•--- ------------ ----- <br /> ---------------- ----- - ------ --'---- •--- -------------------------------- --- ------------- ......--- ----- --- <br /> Final Inspection by:. ---------------------- .---------------- - ------------------....Date MAI• .. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />