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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- -- ----------------- ----------------------- Permit -- <br /> {Complete in Triplicate) <br /> ------------ -------------------- ----------- <br /> Date Issued.-_�:_�..77_ <br /> This Permit Expires 1 Year From Date Issued <br /> ----------------------------------- <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 /> SIF <br /> JOB ADDRESS/LOCAT N,.--.-_ __..... .- -------/-)-----� ` - - <br /> - - <br /> ---.CENSUS TRACT----------- ----- <br /> Owner's Nam :_ ---- -- --------------------r ---------Phone------- -=- ------------------ -- <br /> 2 ---- <br /> Address ------------ r� - -------- C1tY - = Zip <br /> Contractor's Nam ---- � ��� License #-���z-Z�---Phone `% <br /> Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ <br /> Motel <br /> Number of livingnits:-------__------ <br /> Number of bedrooms{Other-Garbage Grinder__ .___.<e_Lot•Size <br /> 4 i <br /> r <br /> ---- <br /> �_.G Size---------- ------ - - -- �------- - ---- <br /> Water Supply: Public System and name_ ------------------ - ------ ---s----- --------- - ------------ ----------------------------Private <br /> A .` e <br /> Character of�soil to a. depth of 3 feet: ' Sand El Silt F Clay E] Peat❑ ✓Sand_y, Loam'❑ Clay Loam El <br /> t - ---- <br /> Hardpan Adobe ❑ Fill Material___"".__.__If yes, type___ _____ __________ <br /> (Plot plan, showing 'size of lot, lo(a`tibn-of-sgst'ern i�i`�lation to well-s buildings�tc-Most-b-e aced on reverse side.) ' <br /> NEW INSTALLATION: (No septic tank or seepa a spit permitted i pu blit sewer is available within 200 feet,) l� / <br /> '/ ✓ �/.. Li uid Depth .`T-------------------- <br /> PACKAGE TREATMENT [ SEPTIC TANK [�' t '' Size_ . _,rr_ <�--- --------- q P <br /> Capacity_ :' Type Material- ---------- ---------- No. -Compartm.encs <br /> c,s <br /> Distance;to nearest: Well----- -----------------Foundati>7n- (�;:----- ----Pop. Linea--_14------------------ <br /> LEACHING LINE : [ ] No. of Lines-------, _-- Length of each line._--- &JO--- ----------=Total, Length. / 0. <br /> D' Box__.' _ =--Type Filter Material_-------,�-�-_De lh-FilterJMaterial---'------- -- ------------------------------------------ r-- <br /> / ---- ------------------a --- <br /> Yes <br /> - � Distance�:to nearest: Well_ 'rG -______.Foundat.ion'�=/fl -"-----_-_Property Property Line_.___� - <br /> SEEPAGE PIT [ s - <br /> Depth_.Z-�----.Diameter--���t?'-�-�----Number---:-�------------�------- Rock Filled Y s No ❑ <br /> JJJ <br /> t 1 Water Table..-Depth- -------q ------------------------------- ---Rock Size.- -------------------------- <br /> --------- <br /> ,� , <br /> 1 - -----.Pro --------------- <br /> DistanceLine----� to nearest: Well-------------�.�-U_____._.__•___;.___.-Foundation_..__.____ ""Q- -_ p. <br /> Date ---------------------------------------------- <br /> Septic <br /> --------- ----- ---) <br /> REPAIR/ADDITION {Prey. Sanitation Permit#--- -------------------�-------- - -'------------ <br /> SepticTank (Spgcify Requirements)--------_ '------- -----=--- -----------------------------------==------------- --------------------------------------------------------------- <br /> -..-.. <br /> Disposal Field (Specify Requirements)-------=-------- � ---------------------------- • <br /> ----------- ------------- ---------------------- <br /> -------------------------------------- <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 /> is Ordinances, State Laws, and Rules and Regulations of'the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: R <br /> i <br /> ' I Certify That in the performance of the work for which thispermit is issued, I shall not employ any person in such manner as <br /> to become subject to. W km' *anCompensation'laws of. California." . <br /> r Signed---------------- t( <br /> __.. _;-'--------------- -- ------ -------------------- Owner t �} Title ----- ----- ---------- ----- ---------- <br /> B ----- {�= t <br /> Y , <br /> (If other than owner) i E <br /> - FO EPARTMENT USE ONLY`' .. .... <br /> ` , .. <br /> APPLICATION ACCEPTED BY -- ----- :' -- -----_ - QATE. "` l - A" <br /> DIVISION OF LAND NUMBER.__.' ! DATE -. <br /> --- <br /> ADDITIONAL COMMENTS------------`_ ----- =. - ' --------- -------------- --------------------- ------------------- <br /> -----------------------------------I------------------------ ----- ------------- - ------- --------------------, ------------------------------ ------------- <br /> -- <br /> _.:..,, <br /> l -- -- ------------------------------------------------------ -------------------------------- - ------------- <br /> ,;; <br /> _ - ------------------------------ ------------------- ------------- <br /> _w q <br /> /-� <br /> Final Inspection b --` -----------------' = = Date.-/ <br /> P y �W_ - - ._ -- -- --- - <br /> EH 13 24 SA AQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 SM <br />