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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------._._..._.-.._ ._----__.- V <br /> (Complete in Triplicate) Permit No..7��.-'-.>� <br /> %./ -- <br /> Date Issued... ................ <br /> ......-.................. ....-.......................... This Permit Expires 1 Year From Dote 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 a d existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION..-.�./1/- ...- /. CENSUS TRACT.-..-_--- ------- ---- <br /> Owner's Name.... - - '- _.. ----- ---.................... - ..... - - <br /> -Address......... ..... <br /> Zi <br /> - � . mss' -- .. ..._._._ City...............--- -e-�-- p------------------------------ <br /> Contractor's <br /> -- - --�-i'- <br /> Contractor's Name_.> --;n - - - - -- ._-- License #.-Y' .i�/7�..._. -Phone_p.��l�-.�.�A--..... <br /> Installation will serve: Residence IV Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--...................- ......... --- . <br /> Number of living units: - ....-._.Number of bedrooms.--. --- . D._.........._._.__ ... .- <br /> g ch Garbage Grinder.........-_Lot Size..... - n. <br /> WaterSupply: Public System and name__.-_---------- .................__.............. .............. .............................................................Private <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 is available within 200 feet,[ <br /> PACKAGE TREATMENT -- <br /> I 1 SEPTIC TANK [ ) Size .__...._..._-_........._.-_------------------------Liquid Depth...._. <br /> Capacity------..-------------Type---------------- ------Material----------------- --------No. Compartments.---'--------------------...0 <br /> Distance to nearest: Well..................... .........__.-._...Foundation___._. . .............Prop. Line----------------------- .N <br /> .. <br /> LEACHING LINE [ J No. of Lines .... .....................Length of each line.-----_-.-.----- .....------Total Length .. <br /> 'D' Box..... _. - Type Filter Material------- ... Depth Filter Material—------------ .................................. ........... <br /> . <br /> Distanceto nearest: Well.............._._.........Foundation.-.-..---._--..--__------Property Line.............._.......---.. ...... <br /> SEEPAGE PIT [ J Depth_-...... .....Diameter--------------------Number__....................____ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth------------------ ................ .....................Rock Size.............------- ------------------- -- <br /> Distance to nearest: Well............--- --------------------------.Foundation----------_-__. ......Prop. Line.._..._._._._.. . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-..._-_--.._--- --------------- ---------------Date................-.---.------------ ._----- .) <br /> Septic Tank (Specify Requirements)..-- ----- ------------r-....... <br /> __ -------------_..------`--.._......___.- . ... > <br /> Disposal Field (Specify Requirements)--._ .. .- --- -- - - <br /> -- - ................ <br /> _ . -- <br /> j�---�---- --"T'� - ---- -- <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 /> to become subject to Workman's Qmponsalion laws of California." <br /> Signed---- - ---....... ... ...__..._Owner <br /> By-----.. ...... -. _.. __... . . . ... .. .. .._ Title.- ------- --------- <br /> ._.-.....- -..... - <br /> (I other than ownerl <br /> OR PEPARTMENT USE ONLY ,1 <br /> APPLICATION ACCEPTED BY............ . .. ...-- -- . .. t-^...............__.....--......--..___------ .DATE -------7. ...� _._....- _ .- ...__ <br /> DIVISION OF LAND NUMBER......... .. _.._.f....___. . --- --- . DATE_.....-- <br /> ... <br /> ADDITIONAL CO MENTS.._-----�lL9C'.-C ,r4C..--.. . ._..-fit. ---.91?-- ✓I--__,44. . <br /> ... .. _ ff: .: .. -- <br /> ----------- ............ <br /> _.....-.. _ ------------------ <br /> - . ----- - -- - -.. ... <br /> Final Inspection b nv-------------------_------- <br /> 04 <br /> - - -'------------------------------ <br /> ..-....Date. L ._- - ._. -.... <br /> w ti 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M <br />