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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ' -3J__ 77- mss// <br /> ---------------------------------- <br /> (Complete in Triplicate) Permit No.---_______ __________ <br /> -------------------------------------- ---------------- <br /> Date issued--- <br /> -------------- <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/LOCAT0 N_-27�_6---- F (� Q <br /> -^_-----�----- -CENSUS TRACT.---- <br /> Owner's Name-:----- ----- -- --- ---- ------------------ -- ------------ -- -----------Phone----- -----.----- <br /> Address -- ------------ ------- ---- - - ---------------------/ city Zip <br /> --------------- <br /> Contractor S Name ''- °' ->�lC License #--3- ? ZZPhone <br /> Installation will.serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Number of living units:._-___ ______Num -Motel ❑ Other-----------_----------------------------___-:: <br /> berEof bedrooms.�.__.Garbage Grinde,r____--_.-__Lot Size______________________ <br /> t ----------------- ---- <br /> I , <br /> Water Supply: Public System and npme__ ___ __ __ --- Private <br /> y . <br /> Character of soil to a depth of 3 feet: `r,Sand ❑. ilt❑ Clay ❑ . Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑/ Adobe Fill Material_.._______ If yes, type___---------------- <br /> . --------- <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�sepfic tank or see ge pit permitted if public sewer is available within 200 feet_,] <br /> PACKAGE TREATMENT <br /> [ ] SEPTIC TANK [ Size_<-! _-_X �' _----_ <br /> rr ----------- Liquid Depth -�---------------- <br /> C <br /> ----- --------- <br /> Capacity {-Z d- Type. MaterialNo. Compartments---- -2-------------------------- <br /> D <br /> ---------- t <br /> Distance to nearest: Well-------------5© ---------------tolundation----- -n- ----Prop. Line--�-' J -- ` <br /> LEACHING LINE <br /> [ r No. of Lines._..___.___3______________Length of each ----------Total Length._.__ ._ ---------- a <br /> D' Box---- __-,-_Type Filter Material-------_S-�___Depth Filter Material----LSI_'----_______________ <br /> ---------- -------- <br /> Distancato nearest: Wel!_.---- ._f? .. -:.Faundation___ �. ----'-.Property Line-------Y�j ---------- <br /> _ <br /> SEEPAGE PIT <br /> { ] Depth----------------Diameter-------- -----------Number------ _-------------_ Rock Filled Yes.❑ No <br /> Water Table De th._-;---______.__-_ -J_r 7,_- . IL"—Rock <br /> . <br /> i p = Rock Size ' `----R-------------] ---------------- " <br /> I Distance to nearest: Well_------------------ '"' ._` `:Foundation Prop. Line '° <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------m..--------------------------------------- Date Date..___.,_--,--_:--'__-- } <br /> Septic Tank (Specify Requirements)------=------------ ---------------,----__-- <br /> ------------------------- ----------------------- --------------- ------- -----------=---- -------- <br /> Disposal Field (Specify Requirements)______________.___.._ �f <br /> I -- -- -------------------------- --- ---------- ---- <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 /> 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 /> tobecome subject to Work an's Compensation laws of California." <br /> Signed_.____- ------------- <br /> , <br /> L. <br /> BY --------------- ----------- fa - ------Title- - .� <br /> - Owner <br /> (If other than owner) <br /> FORD RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- - - -- -- ------------------ ------------------------------ <br /> DATE. l ---------------------- <br /> DIVISIONOF LAND NUMBER---------------------------------------- - - -----------:------ ----------- ------------------- --- -....DATE---------------- - ..-------------------------- <br /> ADDITIONAL COMMENTS <br /> ---------------------------------------_------------.----_'-------._.--------------------------------------- <br /> ---------------------------------------------- ------------ ------------ <br /> --------------------------- <br /> _____---__-_________..________________________________________________________._-__.__ <br /> _________________________________1----_-__.______ - - <br /> p�/ <br /> Final Inspection by ----- Z/s-�"---------_-------------------- ------------------+- -------------- --T-----Date.-----��- -/ - —---- ------- <br /> ------------------------------------------------------------------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />