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FOR OFFICE USE: FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT j <br /> ---------------•--- ....------------- +rG <br /> (Complete_ in Triplicate) Permit Na. .._..____" . ... ._ <br /> --••---------------•--------------------- ----- --------- 3 /�' <br /> Date Issued-.6-'--/. <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION....--.- -- - `? -- -'- - �_'= -v--"--" 'ivEN/SUS TRACT...................... ......... <br /> ' Owner's Name.... ...�.�.11 ..- �/��� +�`5. - Phone... <br /> Address-..-{��.�...Sw :� f - -• ---- City. i . ... -er X&59Zi <br /> S <br /> Contractor's Name----- --,4........i. . __.License #---------------•------ ---..Phone--.----:•---.- _--.--.-.-. <br /> ----------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel [] Other- -- -- ------------------------------------- <br /> y' Number of living units;...s ------Number of bedrooms_.�,..Garbage Grinder------------Lot Size..........- - ._........................... <br /> i Water Supply: Public System and name-­ - ---- s -------- -------------------------------_.........---.... - ------ --------._Private❑ <br /> fCharacter of soil to a depth of 3 feet:` Sand E) Silt Clay ❑ Peat ❑ Sandy Loam (Clay Loam ❑ <br /> Hardpan ❑ Adobe E] 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 /> I ' <br /> PACKAGE TREATMENT SEPTIC TANK � .Liquid p <br /> j } [ } Size-------------- -------------------------- - ----..._.. q d De t ..-- ---............ <br /> ------ <br /> ---T e�-------- -- - - - " � _...._....Pro Line__ ...----------------� <br /> Capacity. . ........ ..... Yp ...... p <br /> .Material.- -Foundation-.---No. Compartments - ------ - ----- ----- <br /> Distance to riearest: Well,."-------------------------- p. ^? <br /> LEACHING LINE } I <br /> I l No. of Lines .:._._..'-------------=•_--.,Length of each line.---.--------...--------.-.... Total Length ... ....._..---------.---_...--..---.-� <br /> 'D' Box.........'I.Type Filter Material...- -- ---- Depth Filter Material------- ---------------------------------------- - --------- <br /> Distance to Weare t: Well--------------------------- <br /> -Foundation. ---------------------Property Line..................... <br /> k SEEPAGE PIT }u Rock Filled Yes ❑ No t <br /> ] Depth. Diameter------------------- Number-------------- ----------- <br /> Water Table,'Depth._.----- --------------- .......------------.Rock Size........ . ._..----- ----------------- -- <br /> Distance to riearest: Well' .� - ----------------------...........Foundation—.............._.......Prop, Line.--...------------ --.---- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#..:.... ..................... .... ......--- --_-/Date--------------- -- ---...--.----.-.---- ----) <br /> ' Septic Tank (specify Requirements)- .- - ----y ---- �'�"'� f� �� -------------------- <br /> Disposal Field (Specify Requirements).. ' = r <br /> ,L j t � ' 1 e �7 '.� ..._ ---------- - ------- .. ........ <br /> ­ <br /> ------------------------------- -------------- . <br /> --------- ............. -- . ... e---------------------------------- _ ... ---•--...­----------------- <br /> f {Draw existing,9nd required,addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i. d .._r. ,.{..._..,r <br /> Ordinances, State Laws, and Rules' and Regulatiof�theSans on 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 ject to Workman's Compensation laws of California." <br /> Signed_ C�l.)_C� -- Owner , <br /> BY--------------------------------- ----------- - • • <�-- -� -................------- -- -..Title---._...------.....-._----------------------------- -...------- --------- <br /> i (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> i APPLICATION ACCEPTED BY........: ------•----- -DATE y' <br /> r ............... <br /> DIVISION OF LAND NUMBER.----------------.................. . . -----....-------- ....:-_DATE...- ------------------ ------- - -------- <br /> ADDITIONAL COMMENTS-. --- <br /> r <br /> t ------------------------------------------------ -------------------------- ..t__ - _ <br /> -- - �- ..............`:.---._=..'-_--------------..--._.._�___i �. <br /> 1 _ _ <br /> Final Inspection b � --------------------Date.-.--��__--.- - - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT21`677 REV. 7/76 3V <br />