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;_ -- <br /> FOR-OF FJCE USc: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT i <br /> --------------:-----------------; --- - "Permit <br /> (Complete in Triplicate) <br /> -------------------------------------- ------------------ ued- � <br /> ----------..----- Date Iss <br /> --------- This Permit Expires 1 Year From Date Issued ._ -7-=-1I-_,7f <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 /> 7 �/: -. 6.+ - lam SP- -�ZAIV� CENSUS TRACT---------------= -- <br /> JOB ADDRESS/LOCATION../ ✓ _ <br /> Owner's Name--- 7?.r1Ly- -- <br /> - ---------- -- ------------------------- --- - ---- ----------:Phone--- -�-�--_�!2_g� <br /> Address---.-'Y7 QG� 10-^- �- City_ll`P�1 0.`. Zip 1r----rte..-�--- <br /> --------------------- <br /> Contractor's Name--- ----- J.W 1 g1L-- -- ------ ------------------ - - ------License #----------- --------•-------Phone---------------------------------- <br /> Installation-will <br /> --------------------------------- <br /> Installation-will -serve:,­­�, ,Residence CF Apartment House [:] Commercial ❑ Trailer Court ❑ 6 x <br /> Motel ❑ Other---------------------------: --- --- --------_ <br /> Number of living units:---- ---------Number of.bedroom s-. _-.._Garbage Grinder------------Lot Size.__-.... ----------------------------------------- <br /> Water Supply: Public System and name------ ---------- :---------------- -- ------------------------------------ .-.-- ------------------------------Private ". r <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam. Clay Loam ❑ i <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,) .i <br /> PACKAGE TREATMENT [ ] - SEPTIC TANK [:] Size- ----- -------------------------------------- -------Liquid Depth.----.- -i_ <br /> Capacity - ------=Type--=-------------------Material---=------------------------No. Compartments-------- --- ---------------------- <br /> Distance,to.nearest. Well.--.-.-.--------- --------------Foundation-- ----------------- Prop. Line----- ----------------- <br /> LEACHING <br /> ----_- -- -LEACHING LINE [ ] No, of Lines_ :---------------------Length of each line-------- :-----------.- ,_.-_.Total Length --------------------------------------- <br /> 'D' Box-- ---------Type Filter Material-------------------Depth Filter Material----------------------- -------------_________------ ---� <br /> t `--- --Distance to nearest: Well------- --- :_..-_Foundation...._.-.-r________________Property Line------______-_...-.-_. <br /> ------ Q <br /> SEEPAGE PIT [ ] Depth....;------------Diameter------------ ------Number... --------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------ -----=-------------=------ -Rock Size -- -------------------- ----------------------- <br /> Distance to nearest: Well_'..-------------------------------------------Foundation- ------.Prop. Line---------------------`-----. � <br /> REPAIR/ADDITION {Prev. Sanitation Permit#----------------------------.-------------------------Date-----.=-------------------------------.--._ _) . <br /> Septic Tank (Specify Requirements)----------------------------------------- = = // ------ <br /> Disposal Field(Specify Requirements___:-----.,_.... �4-�a3_4'�i..--_ -- ^- +-_-_CJ �--------------------- <br /> -------------------------- -- --- --- ---- - ------------------ i <br /> ------------------------- -- -------------------------------------------------------------------------------- <br /> (Draw exis#irig and required addition on reverse side) <br /> AI 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: " <br /> 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 Workrung Com ensation <br /> --- - laws of California.'." ►. <br /> Signed --- - -`�`� � <br /> . --- ----- ---- - -- - <br /> ------------------Owner <br /> ' <br /> BY`# <br /> ---------------------------------------------=---=------------------- -------------------------- Title------------------- ---- -- <br /> (If other than owner) <br /> 'FOR DEPARTMENT USE ONLY a} <br /> APPLICATION ACCEPTED BY---_.__:_-P!-_ <br /> ----------------------------- ------------ ----DATE.------. 71111-7-7------------- <br />' DIVISION OF LAND NUMBER---------------- - <br /> ' ------------------------------------------------------------ - --:------.- -DATE--------------------------------------7--- <br /> ADDITIONAL COMMENTS = ---------------------------------------------- - - - <br /> --------------------------------------- -------------=--=------ ------------------ ------------- ------------------------------------ <br /> -- ----- ------- --- - --------------------------------------------- <br /> ------------=-------------------------------------------- ---------- - - -----------. <br /> ----- - ---- -- <br /> = --------�-------=-= -- --- - --- ----------- <br /> Final Inspection b r� <br /> p Y= = Date.. J <br /> EH 13 24 SAN AQUIN LOCAL HEALTH DISTRICT Fa,s 21677 REV. 776 3M <br /> I <br />