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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ,6 7 <br /> --- <br /> -------------------------- --------- <br /> (Complete in Triplicate) Permit No.--.�- ------------ - <br /> •--•---•-------------------- ------- -- ------••-------- <br /> Date lssued...l_.-�`�.`.7 y <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health D'istr'ict fora 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.. i .--,tet ---- - NSUS TRACT. <br /> 61 <br /> Owner's Name.-....- / -.. . .............. --------------------------------------- --- Phone - --- --- .- . <br /> Address...--- .- ...-....-. - -------------- -- --- <br /> City ,Q-�_/. ZiP / ' <br /> Contractor's Name......-- 7*-)U,,ve <br /> ..._ ..------- License #---j� f�lr I Phone-,`- - --- ✓ :. <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trawler Court ❑ <br /> Motel ❑ Other-- -- ------- ----- ------------------------ <br /> e, <br /> -- --- ----- <br /> Number of living units:---_...------Number of bedroom's_- -6nrbage �i a .......----Lot Size------ <br /> ---------------Private <br /> Water Supply: Public System and name....... ........ . . <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. -__. ....If yes, type-._--------_-------- _J_.-.- <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 /> t <br /> Capacity .. .................Type-----•------------ Material--------------- ----------No. Compartments.------•-•----_--------- <br /> Distance to nearest:'Weil-------------- ....... :_ _- Fouridation.......... ...:........ Prop. Line.------. ..------------ <br /> LEACHING LINE [ ] No, of Lines ---------------------------Length of-each line.--- --._-------..--------- Total Length <br /> 'D` Box-.--........Type Filter Material---' `-....-. .....Depth Filter Material.....-.......-------...................- -------- ------- ---. <br /> .. <br /> Distance to nearest: Well--------------- - �_"`'F-ound`afion--.- ------Property Line...-.-------------- ..---- <br /> , <br /> SEEPAGE PIT [ ] Depth.......... .....Diameter--------------------Number---------- ------ f Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth--------------------------- - - - ----- ----------•-----.Rock Size.----- ------ ­-------------- <br /> to nearest: Well--------------- --------------------------=Foundation........--------.-.... __.Prop. Line.................. ------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------�- --_.._---- --Date.----- ------------ -----] <br /> Septic Tank (Specify Requirements)--------- ----------- --... -.L- - ------ ...... ------. <br /> Dis osal 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, l shall not employ any person in such it anner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed--•- - -------------- Owner <br /> By.............. Title..- -- -------------- ---------------- <br /> (l <br /> at <br /> than 7owP'er) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY................. ..: .... ..DATE <br /> ---------- -------- <br /> DIVISION OF LAND NUMBER -------------- ----- - .................... DATE.---...................-------- ---- - <br /> ADDITIONAL COMMENTS.. .... ............... ...... ...._...----.----_ -I........ <br /> --------------------------- ................................ .....-- .................................... ---------------------------------------.-.............. ---------------.--............ <br /> ---------------------------------- ............ <br /> Final Inspection by:..... ---.. Date...--/... -� ........ .........--. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 21677rR�(;�7a snn <br /> t � I,QCs <br />