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' FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> J'------------------------------------------- <br /> � ,........... <br /> )Complete in Triplicate) <br /> Permit No._.........-- . <br /> .......... <br /> ----------------------------- ------ ------------------- <br /> Date Issued--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 and install the work herein described. <br /> This application is made in compliance with County Or nce No. 549 and ' isting Rules and Regulations: <br /> 70- "-..__ ! G/� .� CENSUS TRACT ----- <br /> JOB ADDRESS/LOCAT __ r3. - <br /> oZ y� <br /> --------- <br /> Owner's Name.----- ---- � t hone . <br /> Address. -a7S --_.Cit - - --- ----- ------Zi ' <br /> ` -- y � ; <br /> Contractor's Name---- ---- ------------------------License Phone- <br /> Installation <br /> hone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel Other:-------------------- <br /> Number of living units:._,.._ ____Number of bedrooms_ -____Garbage.Grinder----------__Lot Size---------- - <br /> Water Supply: Public System and°name--------- ------:---------- ------ ----------------- ----- ----- ---------------------------Character of soil to a depth of 3 feet: • Sand ❑ Silt [] Clay ❑ ' Peat❑ Sandy Loam ❑ Clay Loam; <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.) # <br /> NEW INSTALLATION) �,'(No :septic tank or seepage :pit permitted if public sewer is available within 200 feet,) zI <br /> PACKAGE TREATMENT . <br /> [ ,j —SEPTIC TANKS'__�4-�kiquid Depth ----------- <br /> LA <br /> ---------' 00.._ =T e____ Material__=t__:_ C?� m artments._ -- --- <br /> Capacity-fX yp 1- --__ p <br /> No <br /> ll / <br /> Distance to nearest: Well-.-=--/Oo_'..... .............:......Foundation.. _/O---- _-------.Prop. Line----- s...______-_._-- <br /> Vo r <br /> LEACHING LINE_ ['� No=of Lines.__:_/------------- - Length of each line;---�--__-__-- ------ <br /> Total Length.-.--/.--�_--.__.---------------- <br /> ' ,� _ <br /> Dr, bIygTYpeFilter-Material�x�- �-^'---Depth Filter Material.-- '-'- :------------------- ---- - ------------ --- <br /> - <br /> Distance to nearest.rVl/,eii-�/ C --------------Foundati,-`-- �-- .Property Line_____ __________ '___ <br /> SEEPAGE PIT :[ ] <br /> Depth--4vS. Dipmeter---�-.-.--.-Number_- :_ Rock Filled Yeses- No ❑ <br /> s Water Table Depth. .• = Rock Si e'� -----�'-------------------------------- ' <br /> r <br /> € r. . _ Foundation--'---�-., ----- -- Prap. Line- <br /> -------------j <br /> 1 Distance to nearest: Well-:.-_ 3-0-__-- --- <br /> Date 1 <br /> REPAIR/ADDITION (Prey. Sanitation Permit#_______________ ----- -� __.-- _-- <br /> � . <br /> Septic Tank (Specify Requiremrents) ---------- -- -------------------------------- -------- --- _-=---=------------------------- ------------------------------------------ <br /> Disposal Field (Specify Requirements)-- ----- ---- -------- ---- ------------------------------------------------------f------------=-----------------------------------------'- ---- <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 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 <br /> to become_ subject to Workman's Compensation laws of California." ' <br /> Signed-------- - -=--- -- -- -------- --•--- ----- --.-- Owner <br /> A Title <br /> her than. Dc�.n"�- -1/ _------ - <br /> By- --=------- " ------------------------ <br /> (If ot € <br /> # ' - :FOR DEPARTMENT USE ONLY' ' <br /> APPLICATION ACCEPTED BY- -- - --------------------------------------- --DATE.----- <br /> DIVISION OF LAND NUMBER'--------------------=------------- -- _.DATE-; --------------------------------- <br /> ADDITIONALCOMMENTS-----! ------------ ------ -------------'---------------------------------,-- - ------------------------------------ -------- ----------------------- <br /> ____--!-__ ; <br /> --------------'------------_-------------------------------------------_-.---_---------.-__---____----__________----_------- ------------v ______ ------------ -------______---___._ <br /> ------------------------------------------------------------ -------------- <br /> ' ' -= <br /> Final Inspection yDate ---- <br /> EH l3�34 SA JO QUIN LOCAL HEALTH DISTRICT ras 2T677eEv. ���6 3M <br />