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FOR OFFICE USE: FOR OFFICE USE: , <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------- - "----: ----------- Permit No..7-7r'-�.7-- <br /> - (Complete in Triplicate)-­,-, <br /> ------------- ------------------- ----==--------- 1 2 .j_ 7� <br /> Date Issued-----'----.__._.. <br /> --------------- <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 and install the work herein described. <br /> This application is made in compliance with County dinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION---- <br /> 6= 1_ ---- --- ------------" -------- CENSUS TRACT ---------- <br /> ------------------------- <br /> Owner's Name Ia.e ---- -- n <br /> _ .� <br /> c ---Ci Zi <br /> Address----------- ------------ -------- �1 city. P- <br /> Contractor's Name______________ _ License # 3fP-1 -Phone'514 +�_ ---.--- <br /> ---- <br /> Installation-will serve: Residence Apartment. House❑ Commercial ❑ Trailer Court ❑ <br /> Number of i w..i.. .i..... : Motel ❑ Other--------------- ------ --------------- , <br /> [ living units:___ -:-,-____Number of bedrooms__.--Garbage Grinder__ ;:-.____.Lot Size___ ------------- -- -------- <br /> Water Supply: Public System and name------------------ - ----_--------- -:---=--------------------------------------------- -.--_- ------Private . <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> p ❑ - <br /> Hardpan n AdobeDr Fill Material-------------- 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,] F(j <br /> v4. <br /> PACKAGE TREATMENT [ I `SEPTIC TANK- [ ] Size---- -----" ---------------.-------------------------Liquid Depth.------------------------ <br /> Capacity ------- Type - --------------------Material------- -- ---------------No. Compartments —------------------------------- <br /> Distance to nearest: Well._....-.-------------------------------------Foundation----,-; -- -------Prop. Line--------.------------------- <br /> LEACHING LINE= [ ] No. of Lines..,-.--'-- ------------- -Length of each ling------.----:.--------------------Total Length ------------------------------ ---------- <br /> D' Box-:--------_Type Filter Material --__.:__________.Depth Filter Material__________________ <br /> Distance to nearest: Well----------------------------Foundation----------------------- ---Property Line------------------------------------ <br /> SEEPAGE <br /> ------- -SEEPAGE PIT [ ] Depth----------------Diameter.'------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable.Depth--------------- ---------------=-------------------------Rock Size------------- - --------------------------------- <br /> Distance to nearest: Well----------------------------------------- -Foundation Prop. Line------------ ------- <br /> REPAIR/ADDITION (Prev: Sanitation Permit#----- ----- ------------------------------------�.Date--4----------- --- -------- -=-------------] <br /> Septic Tank (Specify Requirements)-----_-- :__,____ �4-t *E. -- d --.-�--- ------ <br /> Disposal Field (Specify Requirements)- C.tAll, ' ------------- ------------------------ ----- -- - <br /> -------------------------- ----- . -------------------------------- ---- __.,._: <br /> -------------------------- -- ---------� <br /> ------------------------------ ------------------------- ---------------------------------- --'----- . ---- ------------------------------- ------: ------ ------------------- <br /> E <br /> r (Draw existing and required addition on reverse side) $ <br /> i t <br /> I hereby certify that I have prepared this application and that the work-will be done in accordance with San Joaquin County I <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 perlormance'of the'work for which this permit is issued, I shall not employ any person in such manner'as <br /> ei <br /> toqn <br /> e o ject t Workman's .Compensation laws of California." <br /> Sie ---.--- Owner <br /> BY-------------- = ------Title.----------- ----------- :----------------------- --- <br /> � � (If other an �e, " <br /> F0 DEPAR M T USE ONLY <br /> APPLICATION ACCEPTED BY ------ �"`-^ �� DATE _ i <br /> DIVISION OF LAND NUMBER----- ---------- ------- ----------- DATE <br /> ADDITIONALCOMMENTS---------------- ---------------------.-------------------------------------------- --------------------------------------------------------- -- ------ ----- <br /> ----------------- <br /> ------------------------- ---- ---------- ---------------- ------------------------------------------------- ------------------------------------------------------ --------------------- --- -- <br /> ------------------------------ ---- ----I-------------- ------------- <br /> --- ------------------------------ <br /> ------------------ <br /> ----- -- ------------------------- <br /> Final Inspection b pate �-----.-- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7��6 3M <br />