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FOR OFFICE USE: FOR OF1-IU Usk: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No..,; e... <br /> Date Issued__T--- Q--�� <br /> •-...•.••.•............................... ..........:.._ This Permit Expires 1 Year From Date Issued <br /> Application is.1hereby 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. 5'49 a� existing Rules and Regulations: <br /> JOB ADDRESS/LOC ION------- - ----------- +- <br /> ... ...... <br /> - �l...- - -- -- - - ------ �-_ S TRACT--------•--------- -- --------Owner's Name ------• ---. ----------- = _ -----...one... <br /> Address..- _ �.. �------------.-- ............ .. Cit - y.'.'_.....,Zi <br /> Y _ R------ ------------------ <br /> Contractor's Name. �._ License # � f Phone <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel <br /> Number of living units;................Number o bedrooms Other Garbage g 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 ❑ 'oClay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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.) <br /> NEW INSTALLATION: (No septic tank or-seepage-pit-permitted if public sewer is available with-in-200`feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ......_Liquid Depth..................... ...� <br /> [ ] Size --------- --------------------------------....... <br /> Capacity------- - - ---------Type------- ...... Material.-------- --• . ....No..Compartments............. .............. <br /> Distance to nearest: Well---------------- ---- _........ ..........Foundation------- -. ..._ - - Prop. Line....----_.............--.( , <br /> LEACHING LINE j ] No. of Lines - --- ---------------------Length of each line..------------------------.-.-Total Length . . ............._.. --------_------ <br /> `D' Box..... ... .-Type Filter Material.- ......._Depth Filter Material................... ..... .............. ....................� <br /> Distance to nearest: Well..----.-•-------- - Foundation.---=r---------------- Property Line-_-------- .---..__.----.. . <br /> SEEPAGE PIT [ ] Depth.......... .....Didmeter..................7..Number-.-.-------: - 5`------------ Rock Filled Yes E] No <br /> F -� <br /> Water Table Depth = '-..... .... ---------Rock Size-- -- - <br /> Distance to nearest; Well....-,............. -------------------Foundation ...Prop. Line_.....-----.......... ..: <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---._ ......Date---------.........----------------- `.:-----) <br /> Septic Tank (Specify Requirementsl.-- --- <br /> -- <br /> Disposal Field {Specify Require ents)..... ...1. �- . <br /> ... <br /> t <br />---...:---•------------ ---------_--------------- . ...---. .. .. .------.......- <br /> (Drdwuexi-stin ,cin-d 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: a <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 /> BY------- CI - Title------ ----------------- <br /> {i other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..�_S <br /> . ....... .........DATE . -- , <br /> DIVISION OF LAND NUMBER. ....... ---------------------------DATE.....-...........-.- <br /> ADDITIONAL COMMENTS........... ......................................... ----------------- - <br /> -- ---------­ .. ................. .... ................................----------....... ------------------------.. ..- <br /> _ -------------------------------------__........-L _---a --- <br />.................. -----..... <br /> - - <br /> Final Inspection by:.. ----- ....... -- -- --- Date.- ----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 71677 REV. 7/76 3M <br /> } <br />