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' A <br /> FOR OFFICE USE. FOR OFFICE USE.- <br /> 01� .I . APPLICATION FOR SANITATION PERMIT <br /> ----_------ <br /> "..-.....- I �... (Complete in Triplicate) 7� <br /> - .. <br /> ------. .............. ` ----------- <br /> Date Issued...Permit o......... <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/LOCA :.. ....-- _ �- - CENSUS TRACT...---.. <br /> v - .tl------------------------ - ---- <br /> Owner's Name QS.!5� :... ------------------ ,� / .Phone. <br /> Address--- ._.. . .--- . `.. - :_.. .....Cit?'. 75:2 -.`� -- --- -- - --Zip- •� fv <br /> L <br /> Contractor's Name..... _- ,__ '_cS(�/ .. ..............License #- .T-3-Phone.-:.....-----:--._. <br /> Installation will serve: a Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---- ------------ ---------- <br /> Number of living units:-............Number of bedrooms.�......Garbage Grinder--------_...Lot Size.`��x � --.--.- <br /> Water Supply: Public System and name '. ---------- -------- - ------------------.-Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Si t❑ 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 sewer is availoble within 200 feet,] <br /> PACKAGE TREATMENT [ .} SEPTIC TANK [ ] Sizer.----- --- _I—-------Liquid Depth--------------- <br /> Capacity..... <br /> .._:---. -__..Capacity.... .......... ...Type---------- ---- ----- Material--------------------------No. Compartments.....................-- <br /> Distance to nearest: Well---------------------------- ----------------Foundation--.----.-- ---..........Prop. Line-----------....-..-------.N i <br /> LEACHING LINENo. 3 <br /> [ } No. of Lines. -..-�----------------------Length of each line -------=r---------------- ---Total Length .. -------------------- -- -�-------VS} <br /> 'D' Box.........:..Type Filter Material-------- ----- ---- Depth Filter Material................---..-------------------.-----....----...- --` . <br /> Distance to nearest: Well--- ..........:. :.._._-.—Foundation-----------------------_---Property Line- ---------_-- <br /> SEEPAGE PIT [ } Depth......... .....Diameter..-------------.....Number-------------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth_------------------------ - ---------------------------Rock Size-- --- ............ --- -- -- ------------- <br /> - <br /> Distance to nearest: Well---------•---------------..................Foundation..........................Prop. Line------------------.---- <br /> T REPAIR/ADDITION (Prev. Sanitation Permit#-------.-- ----------------- - ..........:-.Date------------•-..-----------.------------------- <br /> ) i <br /> o� �� chi <br /> Septic Tank (Specify Requirements)..............,�G 0.0-------a-91 .... •- f/ I <br /> Disposal Field (Specify Requirements]..!............... . ------------ <br /> .­----------- <br /> ------r--------•--•-•- .............. !...... .............................. <br /> 1 <br /> --- -- ---- I------....------- ------------- •.... .......... -- ....---- - ----- ----•-•- --------- ----- -- - ......... ------------ - ------......... <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 i. <br /> Ordinances, State Laws, and Rules and Regulations of. the San Joaquin local Health District, Home owner or licensed agents <br /> i <br /> signature certifies the following: <br /> "1 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'sCompensation laws of California." <br /> Signed ..._ -------Owner _ <br /> By---- .................Title_._. ` '.�-�yt �L <br /> (Ifother than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...- �._.. .... .N. - . --- -------.. - - .........DATE .. ._ .2.Z_._. .7r1... <br /> DIVISION OF LAND NUMBER....---------- ----------------- -----........... .- DATE. - ' <br /> ADDITIONALCOMMENTS,.------ ----- ------------------------ ------------------------ ---- ---------------- ............--.......................-.....--.- ..... .. <br /> 1l r <br /> - ---- ------------------- ------------ ................. .. . -...------------------------------- ---------------------------- ------ .......... ..... . .. <br /> ­_. ................ <br /> •----- -- ---, .------------------------•1----------- -------------------_---- -------------------------------- <br /> Final Inspection b - ------------ ----Date....- Z -.----------..... <br /> e" 13 2a ; SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/7b 3M <br />