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POR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -----------------m ----- - 7�- S�/ I <br /> t <br /> (Complete in Triplicate) Permit No_ ______ ____________ <br /> ---------------------------- --- ---- ----------------- :-.- <br /> --------------------------------------------- ----------- This Permit Expires 1 Year From Date Issued Date Issuec <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 <br /> No. 549 a d existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI U-..-.-f ......... .....0 `F"`'"�`� <br /> Q -- --- ------------------- CENSUS TRACT <br /> Owner's Name_____________ <br /> w-"--'----------- -------- ----Phone------ ---------- -------------------- <br /> Address._4/y __ .Ci <br /> Contractor's Name ` ------------------------------License #-. '� +_o�e lz <br /> Phone r <br /> Installation will serve: Residence [!�'partment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel °7Other--------------- ------ <br /> Number of living units--- - -------Number of bedrooms_-4r?---Garbage Grinder......__-._l !J <br /> Lot Size...2. _v-...._ --. <br /> Water Supply: Public System and name------------------ '--- -----LiJ'Q ------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay [ Peat[] Sandy Loam ❑ �Clay Loam ❑ <br /> Hardpan E] Ac l- <br /> o e ❑ Fill Material------------- 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,) o <br /> PACKAGE TREATMENT [ } SEPTIC TANK [AJ-' Size_..7-. 5 ---------------Liquid Depth---- .-------.---- - <br /> Capacity/.-20 ,)_____Typep 4- Material-i �yD - __ No. Compartments------------C;Z— <br /> -------- -------- <br /> ol <br /> . _..- - _ ______._--.._Foundatio .- Pro Line__. <br /> Distance to nearest: Well_ -----t--- - ------------ - p• r,7`'�------------------ <br /> LEACHING LINE [ No. of Lines=_.....-.... <br /> ___.Length of each Iine.i e..� .. .... ...Tofial Length ��-.1 .c _$_____..._..- <br /> nn .� <br /> 'D' Box___._ -..-Type Filter Materials//(Qc�.Depth Filter Material--------- $_-..------------------------ <br /> __________________-� <br /> Distance to nearest: Well----------------------------Foundation --....Property Line------------------------------------ <br /> SEEPAGE PIT [ J Depth----------------Diameter------_----__-------Number--------.-_______------_..-... Rock Filled Yes ❑ No ❑ a <br /> Water Table Depth----------------------------- -------------- Rock Size------------- -------- --- --------------------- <br /> Distance to nearest:-Well-----------------------.-------------------Foundation----------.--------------.Prop. Line---------------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_ _______ _ _ Date--------------------------------------------- ) <br /> Septic Tank (Specify Requirements) -------------- -- ---------------- --- -------- ----•-------- <br /> Disposal Field (Specify Requirements)--------- ---- ------- ---------------- ------------- <br /> ---------------------------- ------------------------------------ ------ - --------------------------------------- - --------------------------------------------------------------------------- --------- <br /> ------------------------­-- <br /> ------------------------------------- ---------------------------------- ----------------------------------- ------------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> 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 jec to Wo man s Compensation laws of California." <br /> Signed---- ---- ---- ---------------Owner <br /> - ---------- <br /> BY - ,, le. "--- - Title <br /> (If other than ow 6er <br /> FOR DEI' RTM NT USE ONLY <br /> APPLICATION ACCEPTED BY �e�! _ DATE / 3 ,7 <br /> DIVISION OF LAND NUMBER------------------------ ----------- ---------------- --------- --DATE----------- ----------------- -------- -------= <br /> ADDITIONAL COMMENTS----------------------------------------- ---- -------------- <br /> -------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- <br /> ----------------------------------- ----- <br /> Final Inspection by:- ----- . ... <br /> - . .. <br /> - --------------------------------------------------------------Date.. �'--' ------^-//�� <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV.1/� M <br />