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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............... ....... 6 <br /> l' Permit No..-� .. <br /> (Complete in Triplicate) .---- <br /> Date Issued.-.....,"--.....--- <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 /> JOB ADDRESS/LOC ON__.��. �^--- .�r......���STr� SI.......• CIrNSU5 TRACT............. /-------------_ <br /> Owner's Name.. ...........C" .E........... ........ ------------.......-- •-----------.Phone' P - P <br /> Address...-- ..- .... ✓ v• % City / -C� �� Y Zip � a4-- <br /> Contractor's Name.... -- ..License #. ------- - ---- --- Phone-------=----------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <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 Loom ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material. -_ - - If yes, type---------------------- St <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....q .7� //JJ <br /> �� q '] ---------- -Liquid Depth.----7..................� <br /> Capacity-.OP d-------TYPe-----•--------- --- --Material..i;,J.06-CSF ---.-No. Compartments.------ •-C ..----- ------- <br /> i <br /> Distance to nearest: Well....----1111411 ----.----.....Foundation.-.--/d............Prop. Line......5-- ------ -------- <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❑ <br /> Water Table Depth----•---------------------- - ---- --------------------- Rock Size- .----------- <br /> Distance to nearest: Well---------------- ---------_-----------...Foundation......------..............Prop, Line.-...._.... ........- <br /> REPAIR/ADDITION (Prev. Sanitation Per #............... Date <br /> Septic Tank {Specify Requirementsl...... l. - d .�/ � _-...�.lC3�J�--S� "�-. " -- -a -- <br /> .... <br /> Disposal Field [Specify Requirements]------------------ -- _ � ----- <br /> ------U S b- - ----- ----------------0 <br /> 7-140otV a7A&11�y <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 /> "1 certify that in the performance of thewor or which this permit is issued, I shall not employ any person in such manner as <br /> to become subie a Wo Com�en ti aws of California." <br /> Signed--- <br /> ...... Owner <br /> By------ ----- .......................... ------- .... Title.-------- ----- <br /> (If other than owner) <br /> 1477) FOR YEPARTMEqT USE ONLY <br /> APPLICATION ACCEPTED BY...--- A4�., ....... DATE ../.-7. 7�tlr .. -------- <br /> DIVISION OF LAND NUMBER. ff DATE.. - - --------•----- --------- <br /> ADDITIONAL COMMENT5......7Q rr� 5.45 ---- :-h ...:. a �.. tev► �-w� - �'� <br /> ---------------------------- ----------- IS--.... ----------------.... - .... <br /> - ---------------- ---- ---... <br /> ------------------------------------------ .................. ........ .................. <br /> ................... ---------------- <br /> -- <br /> Fina! Inspection by:--- ... - -Date.---x . .7.5'....... ----- <br /> - ---------------- - - - - - 1. <br /> EFt 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fd.S 21677 REV. 7/763M <br />