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FOR OFFICE USE: FOR OFFICE~ USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -....----- �------------------- --�-�-- -- • � ... Permit N <br /> (Complete in Triplicate) <br /> - Date Issueds7:-��-- <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 /> � ------.CENSUS TRACT. <br /> JOB ADDRESS/LOCATION <br /> _ Phone...." <br /> r•g�3.? <br /> Owner's Name.-- fir ..... �.L` .�',••, ` Il.l..t........... . .•----. <br /> Address----------- ------..y..---------- ..------city- ----------:-----... ....... .Cl..- ------• <br /> Contractor's Name--- ---- ..........License # --------- ------ .......Phone--......---- ------- --- -------- ; <br /> Installation will serve: Reside nceV Apartment House E] Commercial ❑ Trailer Court El p <br /> Motel ❑ Other------------ ---- ------ ! <br /> Number of living units:..._- -_Number of bedrooms.--....-----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 ❑ <br /> Hardpan.❑ Adobe ❑ Fill Material-. ---._.- If yes, type---------------------- <br /> i <br /> (Plot plan, showing size of lot, location iof 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 /> No. Compartments-----• •------ --- ------------- 1, <br /> Capacity-.... ..........--Type--------------- ------Motorial-------- ----------- <br /> :I <br /> Distance to nearest: Well..:--..----- ......... ---------------------Foundation-----..... . ._.......... Prop. Line......... <br /> - <br /> .---.Length of each lin&.-------- --------------------Total --------•------- ----------- I' <br /> LEACHING LINE [ ] No. of Lines..'.................". Tl Length ---- --------- <br /> ' <br /> ' Box..... --...a - <br /> DType Filter Material-- ------------ M <br /> Depth Filter Material ----..."---.- ... i <br /> Distance to nearest: Well...--- Foundation•---------- -------- ----- Property Line------ ----- <br /> r: <br /> -_---- Rock Filled Yes❑ No ❑ <br /> SEEPAGE PIT ( ] Depth.............jJ Diameter'--- -Number_......_---------------- I <br /> i1 • <br /> Water Table Depth--"------- ---------------- - - - ------.----.Rock Size <br /> Distance to n larest: Well--------------- . .....---.- ----------Foundation---------- .......... Prop. Line---- <br /> REPAIR/ADDITi bN (Prev. Sanitation Permit#--------------------- ---------- #103 -----""..--�•-,-,-_-[....-"-- . } <br /> Septic Tank (Specify Requirements)...., ---- " rt/, <br /> ....--.... <br /> Disposal Field (Specify R q irements).:�...'. """""" <br /> k �4 _...... ... ------------- --- ---------- <br /> -------------------.... <br /> .... `-- -----------------• .......... <br /> .,.�. L <br /> j ,:(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`•whtch­this-permit is issued, 1 shall not employ any person in such manner as <br /> to beco a subject. to Workman Is C pensation laws of California." <br /> Signed4� ,tb�J 1 •Ltd -------------- --- ----Owner <br /> ........Title-------------------"-- <br /> By..------.--- ---- --------•---------------- - - — <br /> -(If-othe4-than�owner) __- - - <br /> EOR EPARTM 7 SE ON <br /> k -DATE . ...... ... <br /> ! APPLICATION ACCEPTED SY....-" - <br /> DATE.... .. ........ ..... <br /> DIVISION OF LAND NUMBER .... ----.. k ..-- ---- ------- ------ -- <br /> ADDITIONAL COMMENTS............. ...... - -- ...---------- . <br /> ;i ...................... ........ -------------------- ..----- --- ----..----- - <br /> ......... .. .... .................. <br /> ....... ....... .... <br /> ( ( - ---------- ------- ---- ----- -------- <br /> (� <br /> ... ...._` 7 ---...- <br /> � �------- ---- •- -------- ----- Date...- -- -- <br /> Final Inspection by:..... `c ---r-a/1�-- ----- -�"" �c`�" " " �,CC� � �`�`i�`�� .--- F&S 21677 REV. 7/76 3M <br /> N 13 24 SAN/JOAQUIN LOCAL HEALTH DISTRICT <br />