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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> �1 �, 'j\ Ip (Complete in Triplicate) <br /> Permit No..�........5.-..r <br /> ` r: <br /> .. ,4Date lssued.-7.~? 2. <br /> .'7 <br /> ............ :............................... This Permit Expire �-s 1 Year From-'Date Issued <br /> Application is hereby made to.. he San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made incompliance with County Ordinance o. 549 and existing Rules and Regulations: <br /> ---------------CENSUS TRACT ADDRESS/LOCATION_ �,... �---------- <br /> 747 <br /> - ---- <br /> Owner's Name.... ....-`...f Phone <br /> -- - -- ------------------------------- <br /> Address <br /> - <br /> Address-......' -------------- - ------------------City.................. ................--......... P------ •--------- -�. <br /> Contractor's Name - - 1 -.-------.License # ` -- '! ..... .Phone_----��Q /-4x. -- -• <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> )Motel-E] -Otlier_ - o-' <br /> Number of living units;...... .........Number of bedrooms-...f_,f_, Garbage Grinder------------Lot Size..../.. _ :.... <br /> Water Supply: Public System and name......�---------- ---------------------------T...............-----------• ------- ------------- ------•------- ..Private�'j. <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-• s------- <br /> {Plot plan, showing size of lot,iiocation".of system in relation to wells, buildings, etc. must be placed on reverse side.} ,! <br /> NEW INSTALLATION: (No septictt'a� nk o� seepage pit permitted if public sewer is available within 200 feet,j <br /> , <br /> PACKAGE TREATMENT [ } SEPTIC-:TANK �[ ] Size . / ; -------_-Liquid Depth._.-..------ <br /> Capac'ity.4.0i.._.Type, J----- -----.Material--- ---------No. Compartments..- _ <br /> --------- <br /> -nVel -------- .0—................. on............ ......Distari a td" " Prop. ----- <br /> Line----...-.---.-.----..-.. <br /> LEACHING LINE [ ] No. o lillines....___.. ... _. ......Length of each line-.. -� .Total Length <br /> �" / <br /> D' Box_ Type Filter Material........./ -- Depth Filter MateriaL..1- -..: ----.----- •-----. • ........ <br /> Distanl`C6 to nearest: Well----------------------------Foundation.-----------..------------..xProperty Line-------------- <br /> . 1 itff �-. �.. <br /> SEEPAGE PIT [ ] Depth I- Diameter. -- ... .....Number........ Rock Filled Yes No ❑ <br /> t off- -�-- +.� (� - `�--• -•----- ---- .,�-" <br /> Water TabDepth------------------------------------ ------•----- -- -Rock,Size: <br /> �_e <br /> Distanle to <br /> 'nearest: Well--`-------------------------' --o'�.A_Foun�tion---------------- - ----- Prop, Line..- -----------.--.------_ <br /> REPAIR/ADDITION (Prev, Sanitation;Permit#-•------------------------------ ---- -- ----------Date----.--.--•----------------------- } <br /> Septic Tank (specify Requirements)_ . ..-----... - ------ -------------- -------------- ............ <br /> Disposal Field (Specify Requirelments)-------------------- <br /> ------------------------- ��.... ----------------------------------- ---- .............. .......... <br /> --------------------------- ............................. -:------- -------''`----------------------- <br /> ' y (D.rpw existing and required addition on reverse side) <br /> I hereby certify that-I h ye'prepared s application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, andl�i Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> i 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 Workmlan's Compensatio-n laws of California." <br /> Signed-_- .. ..... ........ <br /> BY k <br /> Title- <br /> ---------------------- - -- <br /> . <br /> If other t an owner) <br /> :I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..IM_ -------------------------- ------- ........ --------- .-DATE .-. ._... <br /> DIVISION OF LAND NUMBS1... DATE----------------------.............. <br /> ,.-----..._-- <br /> ADDITIONAL COMMENTS..----"1----------------------- ..--- <br /> IIM <br /> - - iII ------. ----•- ----------------------------------------------------------- --------- ------ <br /> l� -- <br /> -- <br /> —.. <br /> � <br /> Final Inspection by. <br /> -- - ------ - ------------------ Date —.�� <br /> H 13 24 FSS 21677 REV. 7/76 3M <br /> E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t <br />