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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT / <br /> (Complete in Triplicate) Permit No..�.<-: <br /> ...........•-------------••---.....--- ----------- <br /> ..................... ------------------------------ This Permit Expires 1 Year From Date Issued Date lssued�� .- " <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 co m fiance with County Ordinance No. 549 and existing Rules and Regulations; <br /> JOB ADDRE:SS/LOCAT.ION........�7....+e <br /> ............ Cit ... -------------- <br /> 6 [ <br /> Contractor's Name............... _License #--------------------k <br /> 'C? <br /> ---------- - ---- ------- -- - .._..Phone.......=•---...................... <br /> Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------ --------- -------------- .............. <br /> Number of Iliving units;..... ..._Number of bedrooms _3 Garbage Grinder------------Lot Size.......... .... . ... -------------........ .._ _. <br /> Water Supply: Public System and name. ------- ----------- - ---------.......-•----------------. ---------------------- .....................-..-.Private <br /> Character of soil to a depth of 3 feet; Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam PW <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 i available within 200 feet,) <br /> PACKAGE TREATMENT �Od r <br /> [ } SEPTIC TANK �(] Size,....._, .-.-� - -.-,J-;-------- -----------Liquid Depth-.---�..�-..--- ..� <br /> --..Type//"l!�'eX,%/.�.MateriaL�'D.'h.C., /f_.No. Compartments...-..-r%�.,--------- <br /> Capacity/400-­- ...._------0 <br /> Distance to nearest: Well_..__.__�?_0. ------------------------Foundation----- Prop. Line---- <br /> LEACHING LINE D(J 'No. of Lines ._........ ....... of each line---------- .............Total Length . ----- 7��................. <br /> .)q <br /> - h <br /> 'D' Box....I......Type Filter Material 'x_AAAepth Filter Material......... . ...........-----------------.............._. . <br /> Distance to nearest: Well----.��(f a............Foundation-----�0.. .............Property Line.......... -.�-.- ........ <br /> SEEPAGE PfT Depth.__,?S......Diameter..... 3--------Number...........117------------------ Rock Filled Yes`, ' No <br /> Water Table Depth-------- ----...�. .........................Rock Size-_. ...... -.T,.c'---•------- <br /> i <br /> Distance to nearest: Well..........- ------------------Foundation- ..--.Prop. Line---._5.?1.--4--------- <br /> -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ---------------Date-------------------------------------.- ------ <br /> Septic Tank (Specify Requirements]_- - ..- -- ---------------------------------- ------ - ---------- <br /> Disposal Field (Specify Requirements)...................... ------------------------ ....... <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 /> "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 3�Jject Work an mpatlaws of California." <br /> Signed......L .---- -- ----- <br /> - .-......Owner <br /> By------------------------------------- -------------- ............ Title.......--.-.............. <br /> (If other than owner) <br /> DE ARTMENT L!S O Y <br /> APPLICATION ACCEPTED BY........ ....-DATE ....... -. <br /> - -----•---•--- -- <br /> DIVISION OF LAND NUMBER......--- --------- --- ---- t... ---------- .. _...------...-- ...--......DATE ....... .----- ---------- <br /> ADDITIONAL COMMENTS , ....C7- .......��---- -..� .... .--_ <br /> -----------------1 . . ----( ------------------------ ._.....-. <br /> a._.. ...,Y,r....•y- - ........ --- ---------------------- - --------- ------- <br /> -•--------------- --------- -------- - �.... ---- - tr �--- ----- <br /> Final Inspe�-tlon'b \ <br /> y:. . / �Y1 Date .. �.� ....... .- <br /> F&5 21677 REV. 7/76 3M <br /> EH 13 24 SAN JOAQUINCAL HEALTH DISTRICT <br />