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FOR OFFICE USE: l r ` FOR OFFICL UbE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------....---------.......... <br /> I, (Complete in Triplicate) Permit <br /> ......................................................... This Permit Expires 1 Year From Date Issued Date , <br /> i <br /> i <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 /> ,l <br /> JOB ADDRESS/LOCATION, --•. CENSUS TRACT_---- ----- ---_-------_ ; <br /> Owner's Name... . +:°0r.1._. ..._.. Phone.,..-- •-- ...... <br /> d� ---...- <br /> Address ?- --- -------------- ....City------------ -----------_....................Zip--- •-............ <br /> Contractor's Name_;___. .... -7. _ License #--3e-fl-. Phone AIA!�V',-------.-. <br /> j <br /> Installation will serve: Residence ❑ Apartment.House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other...................... ................ .... <br /> Number of living units: .......Number:of bedrooms..-....Garbage Grindar--.:_---.-..Lot Size-----! - .�1. .................. .. I <br /> E _ <br /> Water Supply: Public System and name.;5...........:.....----------- ------------- -------...........................----------------------- ..Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Slit 4 <br /> p ❑ ❑. Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material.. .... ....If yes, type_------------------------ <br />(Plot <br /> •---------- --{Plot plan, showing size of lot, location of system in rely"lion 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 --Liquid Depth_----- - - <br /> [ } � .,"Size .............. ......--��-�-------...---- <br /> ---------- - _--.-..--. .- --- . <br /> Capacity. ........Type----------------- ------Material---------------------._.._No. Compartments........---------- <br /> Distance to neaiest: Well-----------------.................------_.Foundation.----. - ..Prop. Line-------_.......... <br /> .. -..-. <br /> LEACHING LINE ( ] No, of Lines ...... . - .....Length of each line..............----------------Total Length ... ........................ <br /> _-.-.---- <br /> 'D' Box_... ---...Type Filter Material_... . ..... .... Depth Filter Material................... .------..----------- -.-- ---.---. ------�� <br /> Distance,to nearest: Well......... ..................Foundation_._....---.__---.--.-...-..Property Line..................... t <br /> SEEPAGE PIT [ j Depth..-- -Diameter--------------------Number-.------------------------------ Rock Filled Yes ❑ No [" <br /> Water Table Depth------------------_- ........ .............. -----------Rock Size. ...... ---------- -.---------- <br /> Distance to nearest: Well-------------------------------------------Foundation........-.----- Prop. Line.---- ...... ------------.- <br /> j <br /> REPAIR/ADDITION (Prev. Sanitation Permit#___________________ .-..-.,.-.Date..................... ............. .- } <br /> Septic Tank (Specify Requirements)------ �...- ..---------------- ------ --- ------ <br /> -------- -------------- .. <br /> Dispo al Field (Specify Re uir ents)..:. ... .. <br /> 1-2—.�.... ....-- <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 Son Joaquin Local Wealth District. Home owner or licensed agents <br /> signature certifies the following: .A { <br />"I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California. <br /> Sig <br /> ned.---....-- ------------- ---- Owner <br /> BY -T-- jy: - Title - f <br /> .........I ---------------- ------ ...-.-.........._.__....... ------ <br /> {lf other tha owner] ¢ <br /> FOR DEPART NT USE LY <br /> APPLICATION ACCEPTED BY...................,--------......-------.----- -------,'- _-- - cam..-._DATE ......0-2-.7.5------ ............ <br /> OF LAND NUMBER..._---- i' °.' . .......DATE..... ....... ............. . - -. <br /> ADDITIONAL COMMENTS...... _r4,.i.. �- a <br /> ............................. .................. <br /> ............. <br /> ----------------------•--- " -.- ..... J— ---------------------..._._-----..-- -----..------- ._... <br /> Final lnspecilon 6y: ..../�1�.-Gtr __✓a' C ' -------------- - ^/J�3 <br /> D - .... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH-DISTRICT r&s 2�� 7/76 3M <br /> x` <br />