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v., <br /> FOR OFFICE USE: FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> � cam~ � <br /> . � -----.--- ^ <br /> (Complete in Triplicate) Permit o. ::�.......y�__.. ..� . <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 N , 549 and existing Rules and Regulations: Y <br /> JOB ADDRESS/LOCATION �D. 4�._._.�.�----- . ... .... -----------------------------CENSUS TRACT....... ................ . <br /> Owner's Name.... .... �,�. / - �. ......... :..:. Phone -. d3 ._.---- <br /> (�R- City ._.. :...ZiP l <br /> Address..- - -- --- --------- <br /> Contractor's Name.... - ----•- ---- .......... Phone..`` -�w4!4 .-..... I <br /> .__.License #.�-�.���� �i <br /> Installation will serve: Residence NY Apartment House E] Commercial ❑ Trailer Court El ) <br /> > r otel ❑ Other.............. ....:......... ------------ � r <br /> Number of livingunits:... --.--Number of bedrooms. # <br /> �_....Ga``rbfage Grinder__.____---Lot Size__. -.��. �.��-- -�.:................ . <br /> Water Supply: Public System and name-- - -- ---------C ­ W�. -- 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 /> ]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 szl —1ewer is available within 200 feet,) �, s <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size .y.. . -X _----- _..-___.Liquid Depth.........................�; <br /> Capacity,�A�------Type- -4-tLQ ...Material..�r�Q' .--.:No. Compartments._-._- :• --..`---..-...-.� r <br /> Distance to nearest: Weil__. ....................Foundation._, Prop, Line_4� <br /> LEACHING LINE No. of Lines .....................Length of each line... .-�3_, �:.....Total Length ... ._f.7lQ.�.....---..----- <br /> D' Box.._..k<Type Filter Material-51A.. 11e.Depth Filter Material..,..._ ..Of.------------------ ......... --- ---- I <br /> __. Foundation Property Line <br /> Distance to nearest: Weil_'_'_,,_ . _ -......._....._-_..... <br /> s&EP*ee-mr [ Depth.�.Q_-.. .Diameter. _?�/ ...Number -- f� Rock Filled Yes, ( No El x <br /> y Water Table Depth---------.......-- Rock Size.... ._......... <br /> Distance to nearest: Well....... Foundation.....1/6,...... <br /> ..-- Prop. line.._------------ ----• <br /> r <br /> REPAIR/ADDITION (Prev. Sanitation Permit#..------ • -- --------- ------- -------- -----Date-------------- - ------------ ------- <br /> Septic <br /> -----Septic Tank (Specify Requirements).................... ... ­­-............... . ............. <br /> Disposal Field (Specify Requirements)---------------------- ---- -- -------- <br /> ..................... .... ........... ...... <br /> -------------- -------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 which this permit is issued, I shall not employ any person in such manner as <br /> to become su ct t War an's ompensation laws of California." <br /> Signed------- --- -- - � - � j - Owner <br /> By----•-•-•--•--•------ -L. -------... Title............. ..`----- ............... ..... <br /> (if other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY....... .. .... . 6.) _ DATE: -.-- --z - - ...... . .... <br /> DIVISION OF LAND NUMBER ................_ <br /> ._.....- :._...... DATE--- -------- ------ - -- - <br /> ADDITIONAL COMMENTS-- ---------- - • --- ------------------------ <br /> ----------------- --•-- . ---- ---------------- ........... ......... <br /> -------------- --- - <br /> ---- --- ------ -- <br /> Final Inspection b Date------1. --�- ----- - ----------- -- ----- t <br /> y:....... 4T1 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT fh5 2F677 REV. 7/76 3M <br />