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-FOR OFFICE USE: FOR OFFICE USE: � <br /> APPLICATION FOR SANITATION PERMIT <br /> 5 <br /> (Complete in Triplicate) Permit <br /> 7 <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued._. ' <br /> z <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 /> JOB ADDRESS/LOCATION)- �.� --------------------- 1�1 ' ........... - .CENSUS TRACT. <br /> Owner's Name... - � � � �L�sY- -. --------------------Phone_ZW__ <br /> a .. .... <br /> Address'-_ -------- - ----- � <br /> /. ��- � <br /> =city-- -T�- , / ---------zip ----------------------- ---- <br /> Contractor's Name--'.AIZ -----------..:------ __ _ e <br /> __ -------Licens #. _ =_ _Phone-------_-------------------....... <br /> Installation:will serve:. Residence 5g> Apartment Hou�e'Q,cCommercial ❑ Trailer Court'❑ <br /> ° i otel ❑ Other= ------ <br /> Number of livin units: ` Number of bedrooms. Garbage Grinder.-., ' Lot Size.--------� - — <br /> 4 I i s 1} . ._-..-.. .. , : :: '-. - :: <br /> Water Supply: Public System and name.- :-__-- .:. ---„:.----- -------------------------- Private' ll <br /> Chpracter of soil to a depthof 3 feet: Sand ❑ Silt ❑ °Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> { Hardpan ❑ Adobe❑ Fill Materio,-..._._,__._-]f yes, type____________________.__-.-__. <br /> (Plot plan, showing size of lO't, location of system in relation to wells, buildings, etc. must be placed oln reverse side.) <br /> NEW INSTALLATION: _(No septic tank'or_seepage pit permifted if public sewer is available within 200 fee'tj 6 <br /> MENT <br /> PACKAGE TREAT <br /> [ 1.. . SEPTIC TANK._ [�] .. f Size j�� C ------ Liquid <br /> Depth.,1 <br /> , ' .C�SyMatarial:.-- = - <br /> CapacityF ”-=`TYP? =No. ompaitments---- <br /> .Distance to.nearest:.Wel.l.:...__.. �._--______.__ <br /> -----Foundation Prop. Line__._ _________.__. <br /> LEACHING LINE, [„] No. of.Lin��es//_- _ _.._;__.__:.---------Length of each line_______ Zf________________Total Length.__ - - _______._________'_� . <br /> D Box .. ----Type Filter Materialk_��AP Depth Filter Material _ --l_l�-1------------------------ =._ <br /> Distance to nearest: We11_2 <br /> __ll -_i._-' ` ____ Foundation_.:------------ <br /> -------------Property Line - - --- --- <br /> SEEPAGE PIT? [ ] De' th�6 _____ Diameter.'.._ Number __._____ ._ Rock Filled Yes)' No ❑ <br /> ,_ . <br /> P Water Table Depth-----------------:--------------;----- :: } Rock�Size-_— ------ �--------------------------- <br /> Distance to n r'' j <br /> �.. Barest:"Wel I -- - <br /> ------------------Foundation ----- -=------------ _.Prop. Line ---- --- ,. <br /> REPAIR/AD _._��i' <br /> REPAIR/ADDITION (Prev.'(ProvSanitation Permit#_____:._-_._ � i Date -------- ------------------------------------------------------ <br /> SeptiDisposal <br /> c Tank (Specify Requirements)--------------------------------- �` �� '_�� y - .------ - ------------------------•--------- � <br /> Disposal Field(Specify-Requirements)--------------------- 1-------------- 3 -- -----1--- =--------------------------- ----------------------------------------- <br /> ----- <br /> -------------- ---------------------... <br /> --------------------------------------------J r% ---------------------------------------------- <br /> 'i e _- C� <br /> �_ t <br /> ------------------_________________ _________________________________ _-_._ __.__-__-____.___.-�__�_ _ <br /> F� ___________________________________________________.__--_____.__-_-___.__.___--________-- <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 I <br /> Ordinances, State Laws; and Rules and Regulq#ions_of the. San Joaquin Local Health_ District, Holme owner or licensed agents <br /> signature certifies the following: - t <br /> "i certify that ih-the performance ofthe'"worl, o/r v hick this perrpit isJis'sued, I shall not employ any person in such manner as <br /> to become subject .to or .' an1ss.Cam�er}sa ofi-ldws:.of-Calif ro nia.". <br /> Signed-----< ✓ -�'�"' ------ -------- Owns e 4 <br /> BY <br /> ............................ <br /> - - ie ' <br /> (If other than'owner) F <br /> '- --- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYE '-- -------------- - ---DATE. --9.nt/-f�{ <br /> DIVISION OF LAND NUMBER------ ---------- -------------- ---------------- --------------------- - -DATE.. _------------------ <br /> ` <br /> ADDITIGNAL COMMENTS__.-_-_.- � - <br /> ----------------- <br /> ---------------------- ----- -------------- -- ---------- --- ---- ------ ) <br /> ------------------------- ----------------------- <br /> -------------------------------------- <br /> ----------------- ----------------- <br /> ---- --------- <br /> -------------------=--------- ------- - --------------------------------------- <br /> Final Inspection b - _.- = -- - - _ _ 4 --Date 1 -- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 23677 REV. 7176 3M <br />