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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 7],�3/�' <br /> (Complete in Triplicate) Permit No------ ................ <br /> �- <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 No. 549 and existing Rules and Regulations: <br /> 1 -a <br /> JOB ADDRESS/LOCATION ----{ 3'4. ------ k- CENSUS TRACT <br /> Owner's Name-- ------_.Y_4=------------------ -- --------------------------------- ---- ------------- ---.-.--Phone-------------------------------------- <br /> ------------------ <br /> Address-------------- <br /> -------------------------------------Address-------------- ------- -- --- -- -- ------F CA---------..-City ----- ------ ---- -------Zip-- <br /> Contractor's Name-_- -- - ---- ---- - ` c------ -------------License # -- ZZ Phone - <br /> Installation will serve: Residence [i Apartment House.0 Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Othher--------------``--------- --- --------- <br /> Number of living units:------- ........Number of bedrooms----3__Garbage Grin der------------Lot Size.�;�K•_7.5.-.x_ . ---7 7_3 ..I G <br /> ---------------- ----- <br /> Water Supply: Public System and name----------------------------------------------------------------------- ------------------------------------------------------------Private PK <br /> Character of soil to a depth of 3 feet: Sand E] Silt E] Clay E] Peat E3 Sandy Loam ❑ Clay Loam E]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 seep ge pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size-)-y'--1-A-__ : '__ _r--------------Liquid Depth----V______-_._.--.-_-__ <br /> Capacity.�2 -0--.----Type ---- -------- .....Material��-G�`-C_----No. Compartments--------� - - -------------..-----` <br /> Distance to nearest: Well----------- �_ _.______-__Foundation-_____l._ ------ ..Prop. Line---- <br /> LEACHING LINE Irl/No. of Lines------- Length of each line.____.q, _ _ ..._.._____.Total Lenkth i" �--- <br /> C -------------- <br /> 'D' Box----- ------Type Filter Material.---------J_R._Depth Filter atenal--------1..1-------------------------------------------------- - <br /> Distance to nea est: Well------ �'t Foundation-------- -----Property Line---.. <br /> SEEPAGE PIT [ Depth_._1._ Diameter__._d__ _..._-._Number------ -- , 1, Rock Filled Yes �o ❑` <br /> Water Table Depth------------- —----_--_-------------Rock Size---1--- --1C_._3_._...._____._____------ <br /> Distance to nearest: Well .--_______________Foundation.__-. _ _ - __.._.__.Prop. Line_..__- _c� <br /> REPAIR/ADDITION (Prev. Sanitation Permit#___________________________________________________Date.__.-.__..-_--_-__----.--_.__--_----._-.-_-__.) <br /> SepticTank (Specify Requirements)------------- -----------------------------------------•--------------------- --------------------------------------------------------------- --------- <br /> DisposalField (Specify Requirements)---------------------- -------------------•------------------------ ------------------------------------------•---------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> (Draw <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 /> "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 Wo man'; Compensation laws of California." <br /> Signed------------------ ------- ------------- Owner <br /> By--------------------------------- <br /> - �'1 <br /> (I of er than owner) <br /> F R DEP RT ENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- -CC --- ------ - ---------------------------------------------------DATE <br /> DIVISIONOF LAND NUMBER----- -------------------------------------- - -------------------- ------------------------------------DATE------------------- ------ <br /> ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> e-- - <br /> Final Inspection by:------------------------- ---- - � -__---------------------- Dat �� <br /> EH 13 24 SAN JOAQUIN LO L HEALTH DISTRICT F&S 21677 REV. 7/76 3A' <br />