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FOR OFFICE USE: FOR OFFICE USE: <br /> M APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No....................... <br /> / ...........................f ...... This Permit Expires 1 Year From Date Issued Date Issued .�11��� _... <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/LOCAT-IONTRACT <br /> ----- ---- -. . - -- .. -G <br /> � . -._..C...... . ------�_jf------------- ---.-_-.----CENSUS TRACT------ •- --_-.-.-.-:-._.. <br /> .-Z <br /> --- <br /> OName �jp'77� ----- :....- ............. .....--•-- -.__ ...._._._. Phone. .�� <br /> Address-- z/3 s`3zc. <br /> ..... Zip- ....... <br /> -\--� <br /> , <br /> Contractor's -__ .License - j. <br /> Installation will serve: Residence . Apartment House E] Commercial E] Trailer Court E]tel E] : .. <br /> Other... ..... ....... ...................... ...• 1 <br /> Number of living units:..CJ o_...........Number of bedrooms. .....Garbage Grinder------------Lot Size-----�� ^.......:.................. . , <br /> Water Supply: Public System and.name....... ................ .- . - ------------- - ..-------_Private <br /> � <br /> ----- - - - ------ ---�--- --....-------:•-----------•---- <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 sewer,,i avoilable.within 200 feet,) S <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ..............Liquid Depth.---------....___- <br /> Capaeity.l ��'*-'S.Typ -. Materia!-_.___ ' _Tl, fo:..Compartments-____Z_._. _ - <br /> / f... <br /> Distance to nearest: Well---- _./ _Foundation_.-�� . .........Prop. Line...s. i <br /> --- ---- <br /> �, Total Len a ' <br /> LEACHING LINE [}� No. of Lines..-.--------•...............Length of eaMepth <br /> -_-. .. gth .. ��------_............... <br /> 'D' Box..../_....Type Filter Material.�� Filter Material----------- J............. . <br /> d�� / / <br /> Dism'ica td near,��: We��__. __.. Foundation---C-....-.•-�---......Property Line_...-----_..�.�.- . .....---� + <br /> SEFIT (j D p4h'/� �._D amet r- - -----------N tuber------.--- -----_--------- Rock Filled Yes ❑ No <br /> Water Table Depth------7d_..f................-----------........Rock Size--.--...-- ' <br /> . 1 <br /> Distance to nearest: Well.................................. Foundation......................... Prop. Line-------.------------------- ` 1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------.............. ................Date---------........ <br /> - ---- --------------- ------} �� <br /> Septic Tank {Specify Requirementsl... --•---•--•---------- -------- ----------------- ---- - -- ----------------- <br /> Disposal Field (Specify Requirements)..- J:_-•. CJ._._.. ' c --- ...._ -------.--.Z .... 5 � <br /> ------------------ 1 <br /> {Draw existing and require addition on reverse side) i <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: <br /> "I certify that in the performance of the work for which this permit is issued, (;.shall not employ any person in such manner as <br /> r <br /> to become subje t to Wor maComp ion laws o€ California. <br /> Signed . - ------.... .--- Owner .^t <br /> By-------- --- - ---- .. --------------------------------- --- --- .........Title...... - . I <br /> (if other than owner) <br /> OEPARTMENT USE ONLY r� <br /> APPLICATION ACCEPTED BY.... DATE /. ./a_ ....7 _ <br /> DIVISION OF LAND NUMBER .. -- DATE <br /> ADDITIONAL COMMENTS-- ------- .......................................... ........................ ......... <br /> ----------- -- - . -------- ----------------• '-------------------------- ..................... ------. .._..... <br /> ----•--•---••---------- ....................... ------- ------ ------- ----------- ------------------------------ - .......:. <br /> --•------•-•---•----------------- ------- -- -- <br /> Final Inspection by:------- �� � Date. .� .- <br /> EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT S 21877 REV. 7/I6 3M <br />