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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> •........................................................ No..�B'-:. �.� <br /> (Complete in Triplicate) Permit <br /> Date Issued... -.�-.7..� <br /> ..........••.......-............-••--.......... I � This Permit Expires I 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-comp]iance•with.County Ordinance No. 549 and existing Rules and Regulations: <br /> . ..�. .....�`...1 �_ ......40 in <br /> Address....... <br /> �A.� ._._..-zip...:........._._............. i <br /> Contractor's Nome.... 1�..� . . License #• . -off... Phone..... <br /> Installation will serve; Residence Apartment House Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.......... ................................ fy / <br /> Number of Iivin units:...... .........Number of bedrooms.-5., e Grinder.._ .. • .d .n- :• ........... <br /> g g 1�_Lot Size_....�4. . . .. <br /> Water Supply: Public System and namel..`.`.= r................................. ...._..........._...... ..............................--.._.Private' <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom <br /> -- - Hardpon-F� Adobe ❑ Fill Material.. .... ....If. yes, type............... ................. ,_._ .` _. _.4 <br /> s <br /> (Plot pian, 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 publir� sewer �available within 200 feet,) [f <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ `� r Size . .. �. ..C:�..................... . ---Liquid Depth._.1p ....... � <br /> Capacity-./ .... ype. w rt..Material...(J?��.��No. Compartments.._... ........................N <br /> Distance to nearest: Weft...........12( 6.............._.....Foundation..../.0-- .... Prop. Line.. .... ...............� <br /> LEACHING LINE [ ] No. of Lines .._. ... .......: =of;each li Es.__.. - Toto! Length ..vel ._. <br /> .K <br /> 'D' Box.J... ..Type Filter Material__._,. epth Filter Material.'":­/..............._........_.:......................... <br /> Distance to nearest: Well. ................ProAertY Line..._._ . .`.. <br /> .................. <br /> SEEPAGE PIT Depthi> eter................... u r,, Rock Filled Yes ❑ No❑ <br /> o2}(/GR tat Water Table Depth....................... ............ -...Rock Size..,./..1 ................................... <br /> Distance to nearest: Well.................... .....:~ . .........Foundation_.,.......,...............Prop. Line..................... <br /> REPAIR/ADDITION (Prev..Sanitation Permit#................................... ...............Date...._...._.. ..... ....................... <br /> ....} <br /> . <br /> Septic Tank (Specify Requirements)--.......'.I....... . ......................................................................... ............ � <br /> Disposal Field (Specify Requirements)...: ............................. .................._---•-•-----.-_--.--.------.-_.----.--.-......_....-.--•--..-.---••---_------------•-----•---• E <br /> ............................. ............................. ....... ......_........... ............................. ................................ ".................................. .... <br /> .__.._.. <br /> ............................ ................................................ --- ._.....................---........................................-----............-- --•--..... <br /> 4 <br /> (Draw existing and required addition on reverse side) �— <br /> I hereby certify that I have prepared this application and that 4her 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: I, <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 j <br /> to become subject to Workman's Compensation laws of California." <br /> Signed. � Owner / <br /> ........_..... <br /> ...................Title--W, . <br /> (If(other than owner) i <br /> f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> DATE _. ..... <br /> . _................. <br /> .-- �� ... ........ .. <br /> DIVISION OF LAND NUMBER.............. -- ......DATE..............---........... .. .. <br /> AM)ITIONAL COMMENTS................................ ............. ............ ........ <br /> .............................................. ......................................................................................................................................... ... .... <br /> ....................................................................................................................... .---......_..................................................................................... <br /> ........................................ ...... ---- .......................... ..._. .._._.. ........................... <br /> Final Inspe6on b ................. ..... <br /> EH 13 24 �N JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M { <br /> r <br />