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FOR OFFICE USE: FOR OFFZF USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No...7.` .-_ ..� <br /> -----------• ..................--­-------.-....... This Permit Expires ] Year From Date Issued Date Issued_cS.-.3.L:-?� <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 Regulytiops: <br /> J08 ADDRESS/LOCATION / .1/../...d ------------------ -----CENS�USe TSR/ACT. <br /> Owner's Name---�4&t-4 1._47-5 .-_..... `. ... ---- -----.Phone--- - ................. ........... <br /> Address ..... ... - .. .. City Zip .:. ;.....t <br /> Contractor's Name............. .�`"... -- .License #--�4 _.- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court C] <br /> Motel ❑ Other--------- -- -------------------------- ----- <br /> Number of living units;... _.._.Number of bedrooms. .,...Garbage Grinder__.._......Lot Size... _ ...... .........:............ .... .- <br /> Water Supply: Public System and name.......................................... --........................-------------- -Private h <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam 0 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 seepage pit permitted if public sewer is available within 200 feet,) , <br /> PACKAGE TREATMENT [ ] SEPTIC TANK }` Size. .. . ----------------------------------Liquid Depth.---" ---------------- <br /> Capacity..�cs_Q.C�.-..Type-- - IMaterial- .........No. Compartments_..._.._.. --•---.----.-.- <br /> i <br /> Distance to nearest: Well-------5Z----------------------------Foundation./f0.. . .....-..- - Prop. Line_3:_.-----_-........... <br /> _ <br /> LEACHING LINE 9C No. of Lines....j----------------------Length of each line..... Total Length -----..._..._...-- <br /> Yp p �, <br /> 'D' Box....�..T a Filter Materials De th Filter Material______ __ ______ ------------------------k.-...._........... <br /> Distance to nearest: Well__C�._O..................Foundation........... <br /> .........Property Line-- ................ <br /> SEEPAGE PIT �Q Depth.a S I.._.Diameter_.I.3_�l-- .--Number--..- .--------------------- *� Rock Filled Yes No❑ <br /> Water Table Depth..........1Q.. r �"` ...-----------------Rock Size...07_x'_J� ---- -_--------_---------- <br /> Distance to nearest: Well---- <br /> .. ...........................Foundation.....6*.4d_ ....Prop. Line--- i. -_-.-. <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. Nome 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 jest to Workman' nsation laws of California." <br /> Signed....-- ` ------- - --' Owner <br /> By.............................. - -----Title.- <br /> ----_--- ---------- ---- <br /> llf other than owner) dop, <br /> FO ptPARTME USE ONLY �7 <br /> APPLICATION ACCEPTED BY_...-_.- --�- ..._1..-..�.. -__. �' "L ....DATE <br /> /�( ..--- <br /> ------------ <br /> --�---- ---='...._--.. �- -------- -� - -----------DATE---------------------- - <br /> DIVISION OF LAND NUMBER-------- -- . --------- --- --- --------- ---- <br /> ADDITIONALCOMMENTS----------------------------------------- ---------------------------_-------- ----------------------------------------------------- --- ------------ <br /> -------------------------------------------. .................----._..._.......--•-----......................... ----------..._--•- • .-• ----------------------------------------.................................. <br /> ................................................ ----------------- ---— ­ ----------ff- ------------ <br /> Final Inspection by------ - --------------------- ------------- ------......-------------• -� •� ...._ ._ ..... Date...b.--'1.� �.. ......... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALT IST RICT F&S 21677 REV, 7/76 3M <br />