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FOR OFFICE USE: �' i FOR OFFICE USE: <br /> APPLICATION FOR SANITATION <br /> --------------------------------- ----------------------- W�J <br /> [Complete in Triplicate} Permit No------------------ ---- <br /> ------------------------------------------------------ <br /> Date Issued.-7—//.....------------- ------- -------------------------- ----- 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 c mplionce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT _------ e �� CENSUS TRACT.. <br /> Owner's Name LGI < '� ----"--- - - ---- - - ----- ------------- - ----Phone <br /> ------- <br /> Address-_- -- - ---- ----- - ------r..- 2_,- ----------lit/-�. �". u/.�`-(i-�-..---- - City- }��' p ... Zip <br /> Contractor's Name.---�_-0 6------ 0-t----�--- ----- --..License # f;,�- 4, ----Phone------------------------------ <br /> Installation will serve: Residence a---A—partment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------------------------------- <br /> Number of living units:-------- --/---Number of bedrooms.-----Z--Garbo e Grinder a---.Lot Size._ <br /> WaterSupply: Public System and name------------------ ------------ ----------------------------- ------------------------------------------------------ --------------Private V <br /> Character of soil to a depth of 3 feet: Sand ❑ Siler Clay E] Peat E] Sandy Loam E] Clay Loam EJ <br /> Hardpan ❑ Adobe Fill Material--_-------.-If yes, type-------------------------------- <br /> i <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 seepit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ Size--------- ---- ---- ----� ---------------------Liquid Depth --- ---- <br /> _ L� - r <br /> r T / L/ apacity- -------Type---------- ----Material_ _ ;--No. Compartments__--- � <br /> Distance to nearest: Well----------------------------- <br /> f ---- - <br /> -------Foundation------- ----- ------------Prop. Line----- - --- ------ <br /> - <br /> LEACHING LINE [ ] No. of Lines-----------------------------Length of each line--_--------- ----- ----------Total Length -----...----.-..--_.----------------._ <br /> 'D' Box------------Type Filter Material--------------------Depth Filter Material-------------------.-------------------------------------------. <br /> Distance to nearest: Well------------------------ Foundation___---- Property Line------------- --._ <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No L].� i <br /> Water Table Depth---------------------------------------------------------Rock Size--------------------------------- <br /> Distance to nearest: Well-------.---------------------------------- _---Foundation------------------------- Prop. Line---------------------- <br /> REPAIR/ADDITION (Prev, Sanitation Permit#____F-----------------------------------------------Date__-----__-----___ --_-------_-----) <br /> Septic Tank (Specify Requirements)----------- -- ----- <br /> --------------- <br /> Disposal Field (Specify Requirements) '------ -------------'--- -------- x ' -------------- <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 subject to Workman's Compensation laws of California." <br /> Signed-------------------- ------------------ Owner <br /> -n-- � - -- ------- <br /> By----- --------I------------ `" Title -------- v}-------------------o <br /> (If other than owner) <br /> - - /FOR DEP ENT USE NLY <br /> --- ---DATE ,/ .APPLICATION ACCEPTED B -- - - /-- ------------ <br /> DIVISION OF LAND NUMBER------------------------------------------------------------------------------------------- --DATE---------.--l----- <br /> r <br /> ADDITIONALCOMMENTS---------- ---------------- --------------------------------------------- ---- ------------------ <br /> ------------------------------------------------ ------------------------------------------------------------------------ -------------- ---------------------------------------------------- ------------ ------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> Final Inspection b -------- -- �n--'~r - ----__--Date--_---- 1 <br /> p y:- ! <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />