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FOR OFFICE -USE.- FOR OFFICE USI:: <br /> APPLICATION FOR SANITATION PERA&T <br /> Permit <br /> .................. . .............. -- <br /> (Complete in Triplicate) c� <br /> ------------- -----------------....... Date Issued-- .'c�.---"--- <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 Ordinance No. 549 and existing Rules and Regulations: <br /> a`�3 few S - -• - e . . p 4 <br /> 1 ..: ------CENSUS TRACT........ --.- -�: - - <br /> _JOB ADDRESS/LOCATION............. .... -- ------ Phone <br /> -- --•-----=Owner`s Name. T!?A/ S7-.o �...... <br /> p . 2 <br />' Address �d l Gty. %r3 C Zi . <br /> I,....... c• ...� . rr� - ....:. g- <br /> Contractor's Name A • t�`G - -_....Gam--- ---------- -- ._..... License #._ .... :: } <br /> Phone.. <br /> Installation will serve; Residence ❑ Apartment House ❑ Commercial PR� Trailer Court ❑ <br /> Motel ❑ Other...- .------- ------ ------------ n <br /> Number of lining units:.............-Number of bedrooms............Garbage Grinder.........---Lot Size.--....:.. - <br /> Water Supply: Public System and name--- --- ---------- <br /> •--------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ FIN <br /> Hardpan ❑ Adobe ❑ Fill Material.. _... _ ..If yes, type..- .......-11 <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,) <br /> PACKAGE TREATMENT [f] SEPTIC TANK [ ] Size... Liquid Depth.....--------- ---- -- <br /> Capacity.:.... .:....... .....TY_pe--....----- ... ...Material.......................:_No. Compartments....-- •-----•-- - <br /> t Nstance-to nearest: Well-•--•..... ............. ..... .....Foundation...... _. . ..... ._.Prop. Line :.... <br /> LEACHING LINE [ ] No. of Lines------- -------------- Length of eachline---------------------------- . T <br /> ._ otal Length ....----.....-,=--.. ..--- <br /> 'D' Box...--. ....Type Filter Material........ .........Depth Filter Material- ... --- -- ---Q <br /> Distance-to nearest: Wall------------ <br /> -- Foundation----.----s'------------.....Property Line---------------------- ---- -• <br /> i< Filled Yes No El-, <br /> SEEPAGE PIT " [ ] Depth -... ---Diameter....-- -----• ------Number - <br /> ��------�--- ------- ------ Roc <br /> - ❑ <br /> Water Table Depth-------•------------------------ --- .....Rock Size-- --------.-------..-....-................ <br /> -- <br /> [ r t <br /> ' Distance to nearest: Well------------------- -._-_---..Foundation------ ---=------ ...;_..Prop. Line-- --- ----------- - -- - <br /> REPAIR/ADDITION (Preva Sanitation Permit#-----------------------i-­ ..... .. ...........Date........:--------- '- ----..- ] <br /> Se tic.Tank (Specify Requirements)-- --- -------------------------------------- ---- •.....--- .. ..:------. <br /> I zd/Y�- - v -•------ ------ ------------- <br /> Disposal Field (Specify.Requirements)"""" .G17 -- -----,�-y•.-•--•----.-- <br /> j � ... .... . . . <br /> ""G.' ... .... C.` ....... <br /> l <br /> ------------ <br /> -- _ ----------- - --- --------•------ . <br /> ........ .........•--. <br /> + {Draw existing and required addition on reverse side) <br /> r. <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 Laws, and Rules and-Regulations of the San Joaquin Local Health District, Home owner or litensed agents <br /> signature certifies the following: `�• r� <br /> "I certify that in the•performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> i to become subject two Work - n' C�ommppensation''laws of California." <br /> Signed. ;... ---- -------- ------- <br /> -----Owner <br /> I , <br /> ..._ Title----------- ---------- <br /> (If other than,owner) <br /> FOR DEPQftTIVIENT USE ONLY <br /> el <br /> APPLICATION ACCEPTED BY._. :' ..: ...DATE --�� - <br /> DIVISION OF-LAND NUMBER ".:— _.. __ - -�__ --_- - ...: <br /> DAT <br /> i ADDITIONAL COMMENTS._. _. -Q..-.. -_ . �` <br /> - - <br /> • e <br /> ............ <br /> ....-.i..__-------- -----------------------------•-------------------- .......-.. <br /> ............................. _ ...._-. <br /> fy ............... .......... ........ ......� __....._...-_--...._-........------..-----...----- - -t-e _... <br /> Final�lnspecfion by:... -----..-... Date 7e 3M <br /> eN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&S 21677 REV. 7/ <br />