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FOP OFFICE USE: r FOR OFFICE -USE <br /> APPLICATION FOR SANITATION PERMIT <br /> - ------- -------------- <br /> (Complete in Triplicate) <br /> Permit No. <br /> l Daterlssued_./a_�...�_ <br /> tt -- <br /> This Permit Expires 1 Year From Date Issued l <br /> Application is hereby made to the San Joaquih,Ao4Health District for a permit to construct and.install the..work herein described. <br /> This application is made in compliance with Courity'Oreliriance N __,549 iand existing Rules'findg2egiilations: <br /> el <br /> J ftp . US TRACT-------------------------- ------ <br /> JOB ADDRESS/LOCATION ---- - - <br /> Owner's Name....F--- - - ' - - -------."Phone----------.- ------------------------- <br /> y <br /> Address---- 4�- <br /> - -------- ---------------- -------City--------------- -------------------------= --Zip-------- <br /> D � ---- ----------- <br /> License <br /> ------_ <br /> LicnseContractor's Name.-: ---------- �-- ---Phonee -- <br /> _Jl <br /> Installation will serve: Residence- Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> ' 4. ,., Motel __❑.Other _ = _ - v = <br /> Number of living units:------ ------Number of bedrooms:---�_--Garbage Grinder---.--�-.---Lot Size-,/.A0:X� �----------------- <br /> _Private Eli,/ <br /> Water Supply: Public System and name.__.. <br /> Character of soil to a depth of 3 feet: iR Sand ❑ :5ilt❑ .Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> . . . <br /> Hardpan ❑ `s. Adobe❑ - Fill Material.....:___--If yes, type---_."""._____".."._-- -"_�__ .� <br /> . t= <br /> (Plot;plan, showing size of lot, location of,system in relation to-wells, buildings,etsc._mustrbe placed on reverse side.] <br /> r n � . <br /> NEW'INSTALLATION: i(W septi41 c tank `or seepage pit permitted'if public sewer is available within 200 feet,) <br /> /� 'Li 'uid Depth.-le/_ <br /> PACKAGE TREATMENT, [ ] —SEPTIC TANK [ ] Size.__" -- {Q---------. q _ <br /> ir :._ Material--- --:.No. Compartments •fi----------------------- <br /> Ca <br /> i pacity-�- �Q =TYp? '= rG �. <br /> _.__.__. <br /> neaWationrpDistanceto _ Found <br /> --- - <br /> LEACHING LINE . E ] a. of.Lines--- _ ._.__,Len th.of each line.___�'-f.�__________ _ ___Total Length --------------------- <br /> . D' Box--- _i.,�Type�Filter Nlateria �� _ oundatian_--eL7 �--- ---1------�,._,Propert ----�-------`--- ---------------- --`---� <br /> ---- . Depth Filter Material._,"_-_ <br /> Line_ s <br /> Distance.to nearest. Well- r , y Li ----- <br /> SEEPAGE PIT =[ ] . Depth a'��d.`.-Diameter._ - ---- -----Number---- ---------------------- <br /> Roc <br /> --------- ------ Yes No <br /> - Rock Fill ! <br /> Water Table Depth ,------= ---- - - z Y --------- ---- <br /> YRock Si e__ <br /> t <br /> t - ---µFoundation ._ - Pro Line. <br /> Distance"to nearest: Well - 1� , <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-- -___ <br /> -Date- ----- -== ----- :- - -------) Y i <br /> - - d r <br /> Septic Tank (Specify Requirements)--- _ —------------------ - -- --------------------------------------------------------- ----------- --------- <br /> -- <br /> Dis'posal Field (Specify Requirements). -- ---------------`---------------------- =------------------------------------------- --------------------------------- <br /> ----------- <br /> ---- ---- ---------- <br /> ' <br /> y <br /> (Draw existing-arid required addition on reverse side) <br /> I hereby certify that] 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. Homeowner or licensed agents <br /> signature certifies the following: <br /> ' "I certify that in the performance of'the work for wh-ich this permit is.issued; �l shall not employ any person in such manner as <br /> l - - nia.',' . <br /> F to become subject to Workmams Compensation laws of Califor <br /> p <br /> Signed--- <br /> _ Owner <br /> .: Title <br /> r e (If other than'o her' y <br /> 'FOR DEPARTMENTUSE <br /> APPLICATION ACCEPTED BY � .................. <br /> DA <br /> TE ID 7 � <br /> - -- - <br /> DIVISION OF LAND NUMBER=- --=------------ ---------- ---------------•:.---- - - _.DAT ----:--- --:--- ---.�--=-_ <br /> ADDITIONAL COMMENTS -------------------- <br /> ------------------ ----------------=----------- `------------:--=------------------------------- <br /> i ---=-------------------=------- ---- -----------------------------------. -- <br /> - ----------- -- - ----------- <br /> x ------------------------------------------- --- <br /> --- <br /> - <br /> ----------------------------------- -------------- <br /> Final Inspection•by �. .�a - --- -------Date_�_7� 2 <br /> -YL,j� EH is sa SAN JOAQUIN LOCAL HEALTH DISTRICT 4 Eas 21677 uev. r��b am <br /> I - <br />