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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -----------------------------.................... <br /> (Complete in Triplicate) Permit <br /> i Date Issued_el_i7-.7,... <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/LOCATION. r -._....-_.. ...... ,. <br /> . - .... ..-- _� -..d... ''.��G.__�..-- -•-- - - -------- = . ..........Phone.-- �... ./�} <br /> Owner's Name.._. ��yy <br /> Address....!/.9.x'15---, ,-�-' Q.- .� ® Pb... .j.S..... ..�---- - --- City.:55. C�.-C. _7`d....i�........Zip.7- ...... <br /> �. ....License #....` ...................Phone..-----=------- --...--- <br /> Contractor sName----°------------------- ------ --......-�---- .....--•---..-..- -- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> /' Motel E] Other...... .....----------------• / p <br /> Number of living u .`?".nits:.._ :.__...Number of bedrooms..�--_:...Garbage Grinder............Lot Size._..uls..../._. .G-.j' - ........ <br /> Water Supply: Public System and name....._... - - '=_ .:�_:`:. ._.... _` •-- -:-.......Private 11Character of soil to a depth of 3 feet; Sand ❑ Silt❑ Clay ❑ Peat E] . . Sandy Loam El Clay Loam ❑ ; <br /> Hardpan ❑ Adobe E] Fill Material.. _.. ....If yes, type. :_._ ...... <br /> (Plot plan, showing size of lot, location of system in relation to wells', buildings,.,etc. must be placed on reverse side.) F <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.---- ------ -vo <br /> Capacity - -- -- - --------Type---•---------:---- --- Material-------------,}------•-..No.' Compartments------- •------- ...... �. <br /> Distance to nearest: Well.`-------------.-.- _.Fouriclation...._... ...._.Prop. Line.._.---------.--•---....... <br /> LEACHING LINE [ j No: of Lines.....-----------------•.....,Length of each Tina.------------------------ Total Length ............................ <br /> e <br /> 'D' Box............Type Filter Material_..... . ... ... Depth Filter Material.. .---------------.-----._.....-------------------------------. <br /> - c <br /> Distance,to nearest: Well............... ---.Foundation--------------.-.............Property Line------------------------.----------- i <br /> SEEPAGE PIT E ] Depth__- ...._ Diameter--------............Number------------------ -------------- Rock Filled Yes ❑ No <br /> Water Table Depth-------------•- ._------ -------------------.Rock Size.---- -- . .. •----- <br /> Distance to nearest: Well................... .............Foundation-.__...t..--------------Prop. Line--.--.-.-----_---..---- -- <br /> REPAIR/ADDITION {Prey. Sanitation Permit#------------- - Date-----------------------------.-...........-----) <br /> Septic Tank (Specify Requirements)......... ..... -------- ----- .... ... -- , 1--:---- ....... ----.....--------- <br /> Disposal Field [Specify Requirementsl.... --------------- a" -- :-_- -----..X- . <br /> * . . . ......... .. ¢n.� :--------------- ....-_........---...--- - --------- ------------•------------- -- ---- --- ---- ---- ---­--------------------- <br /> ---- � <br /> ------------......------...------ ------ ................. -------------- <br /> --------------------- <br /> (Draw existing and required addition on reverse side) I <br /> I hereby certify that 1 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 focal Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that-in the perfarmonce of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become sub' to Workman's Compensation laws of California." <br /> Signed i`y .= .Owner . 1 <br /> By------------------------ ------------------------------------------------•- --____................__Title----------.. . ------------ ....... -------------- -------- <br /> (If other than owner) <br /> FOR DEPART T USE ONLY <br /> APPLICATION ACCEPTED BY....- -DATE ---- -- - ----7. --7-9- _ .......... <br /> DIVISION OF LAND NUMBER .............. . -- ----- . DATE... <br /> ADDITIONAL COMMENTS....---..... --- .. --- ......... <br /> -------------------------------------------- --- ---- - ---- ------ - --- ----.--- __..... <br /> Final Inspection b ------- - ----------------------- ----------Date. --- - --- <br /> EH 13 24 SAN AQUI LOCAL HEALTH DISTRICT Fa 21677 REV 3M <br />