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a <br /> FOR OFFICE USE: FOR OFFICE US <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------ - <br /> (Complete in Triplicate} Permit No./.0_-.5_;6_ <br /> ••-------------------------------- <br /> --- . --------... Date lssued57;54�7 .. <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 ani i stall the work herein described, <br /> This application is made in compliance with County Ordinance No, 549 and existing Rules and.Regulations; <br /> JOB ADDRESS/LOCATION.___. _ -_`. _...:.. .... . CENSUS TRACT....-.....- <br /> ..._..-- . -------------- <br /> Owner's Name.... "�'` j.�'. � -- -- -- -- --- -------Phone.-.-, <br /> AddressesV-A-,.&-.,r�.. ..1� . . .... . .... . .. ....... City----- . . ---.......... ZiP--- ..... .. ...... <br /> Contractor's Name........ .. .. .. ©#"- <br /> y-t�L_ --- ---License #� 0_ Il.-1.. .Phone--- -=-- -- - --- <br /> Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------ --- ---------------------------- , <br /> Number of living units:- ..-./--------Number of bedroom .._..Garbage Grinder------------Lot Size-.._A�A. -------------------- <br /> Water <br /> - _---•-----------Water Supply: Public System and name-- ..... ....../0.r __...-........ ---------:------ -------- ----•--------- --.......--------- : ...Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam [] Clay Loa MA ; <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.] may. <br /> NEW INSTALLATION: • (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,[ ®i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] - Size _. (. -4--)c SOS'---------------------------Liquid Depth.....­..---.------- <br /> Capacity..1.1pt.4.Q. -----Type----_eAy__.._-.....Material -C; rj-----.-- -.No. Compartments----..Z9 _ <br /> Distance to nearest: Weil..------- i-... Foundation....10 --- Prop. Line..-. ^ ------------- <br /> LEACHING LINE [ ] No. of Lines . . :_ ..-- .....Length of.eacli line....... -h- -----------Total length .. ..fin----------- ----------- <br /> 'D' Box..../.. Type Filter Material--- Depth Filter Material....- -, ._... ...... ............................... ... <br /> Distance,to nearest: Well.................... .......Foundation.-.-.---..--_-----------.-Property Line-.----------- <br /> SHPA-em PI'f [ ] Depth .X/401./;�iameter------------------- Number-.-_ --------------------- Rock Filled Yes No❑ <br /> Water Table Depth--------------- <br /> Distance to nearest: Well..... . . _ . . ....--. oundation_.A7..t)........ .....Prop. Line....�1...---.---.-----..-. <br /> REPAIR/ADDITION (Prev, Sanitation Permit#................................... .............Date---------------------------------------- ----- <br /> Septic Tank (Specify Requirements)-..... ------ ------------------- ------ --- <br /> Disposal Field (Specify Requirements)-- -- ---•. ...... : . ............. . ...............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 taws, 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 Compensation laws of California." <br /> Signed.. ... . ----. ...-- ----- --- ---Owner <br /> BY ............ ---------- - ------------------ ­ ­.. <br /> (if other than owner) <br /> TR D PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- <br /> ---- ----------- - QATE ..1Z -- <br /> DIVISION OF LAND NUMBER ----------- --------- •-----------._....-- .DATE. <br /> ADDITIONAL COMMENTS................. ..... ... ------------ --....._.. <br /> --------------- -------------- --- -- -------------------------------- ------------------ ----- .......... ........-.................--.....----...............------------.....----.--- --. . --- -- <br /> ...................... .• --- --- - --- - - ---------------------------- -- ---- <br /> ..........- --------- ------------ ?-- --- <br /> Final Inspection by:....- <br /> Date..5. I-7. ...... ..... ........ .... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />