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„FOR;•Crl FICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> '-------------- --- - <br /> --------------------- - (Complete in Triplicate) Permit No,7g-__ _.-F-fes--- <br /> -------------------------------------------------------- <br /> Date <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 /> -- �,. CEJ <br /> JOB ADDRESS/LOCATION...- .s .- - --_-- ---R -.-.CE US TRACT.------. ---- <br /> ` �.�..v, '�c--- ------------------------- ------------- ---------------- -------------- Phone-------------------------------------- <br /> - <br /> - ------------ E <br /> Owner's Name-,_--(?.. _ _. -•------- <br /> Address ----- -5 -- ---------- - ---. ------.City T& C ` = -Zi ---- -- <br /> Contractor's Name ----- � License # Phtone - / <br /> f Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court [] j ' i <br /> Motel ❑ Other_-----_-=:= - = . <br /> '61mber of.living units: _ _._._3 ----Number of bedrooms_._aC __Garbage Grinder Lot Size___ 4f�U. ------ <br /> Wdter Supply: Public System and name :':_:.:= . = r :. _�� Pilate <br /> Character of soil,to a depth of 3 feet. : Sand ❑ Silt❑ Clay ❑ : Peat,❑k Sandy Loam ❑ Clay Loamk[] �. <br /> r •.�".'`, Hard an Adobe FiI I Material. ----If es� e___ ° <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,-etc, must be placed o,n reverse side.) ' r <br /> NEW INSTALLATION:— .(No septic tank';or -seepage pit petrmsitted'if public sewer is avaiiable within 200 feet,) <br /> PACKAGE TREATMENT [` ] SEPTIC TANK'- [ ] '• S.ixe-_ _ _�/ -_ -------------------Liquid Depth___-_t)---/---------- <br /> ��11 _ <br /> Ca acit _!�s4G- '__ T e.f2IeCe;__ yMaterialt _•_-- --------No. Com artments._._ s� }_ <br /> 3 p �YYP7 t -- <br /> # . - i = .-Prop. Line---- _ <br /> ,� .. Distance:to nearest:.Wel.l..___ _�._-... _ _______________i-o`undatian __-/_ - ____ <br /> } g i rI-- - <br /> LEACHING LINE [.} No, of Lines.__;.;k­ gth. __�/.__._JG�_----_--------------- <br /> ::_�__ __` ,.__.Len th-:of each line•..,.__ : __ Total Le// / k <br /> Z <br /> ;D' Box_�.___`__Type Filter Material� De�thi%%filter Material ___. _ ;__.___ --------------------- ----- <br /> Distance•to nearest: Well_./�10------€_.y-----Foundation---_ _________________Property Line------- <br /> SEEPAGE PIT [ ] Depth-----------------Diameter.__.____:_______ ."Number-------------------------------- Rock Filled Yes ❑ No' <br /> . : F <br /> j <br /> Water Table:Depth -'-------- --'------- - _.Rook Size: } <br /> � F � . _ <br /> Distance,to"nearest: Well 'r ' , - `r-fFoundation----.: ;_.Prop. Line- <br /> r , <br /> ' t <br /> REPAIR/ADDITION (Prev.-SaAitation-Permit# ________ ____ _ ._. Date--_--..---,_-._--. } <br /> _- ` <br /> Septic Tank}(Specify Requirements) - -- ----------- <br /> °- ---------------- ------------------- - � - ----------------------------- <br /> _-----------•------- <br /> I I <br /> ` Disposal Field (Specify Requirements)----------------------- <br /> '..`� '.,� -;---- - -- ------------------=- - � - ----- -N- ---- <br /> k. ,, __ <br /> (Draw existing and required addi i&-on reverse side) 17 <br /> 1 hereby certify that I have prepared this application-and•-that-the•-work-fwill-be-done in accordance with San Joaquin• County <br /> Ordinances, State Laws, an_d Rules and Regulations of the San Joaquin Local Health District. Homeowner or licensed agents <br /> signature certifies the following: 4 <br /> "I certify that in the performance of'the work for lwhich this-permit is issued' .I "shall hot employ any p rson in such manner as <br /> to become subject to Workman Comp nsatioril laws of California." _� f <br /> g. . a _ .-. .! - = Owner i <br /> Si ned <br /> ti <br /> BY---------------- - -- -- -- =- -- ----- ---. _Title_..---- --- -- -- --- -=-- ------- - - -------- <br /> (If other than owner) '.. <br /> " FOR:dE RTM NT JJSE ONLY <br /> I •: + <br /> APPLICATION ACCEPTED BYj_ -- . ..-- t ,------=----- ----------r DATE.1- 14 <br /> DIVISION OF LAND.NUMM&R'= - = - - .r �:,.=—DATE». _,__ f .-:.-- .- <br /> -------------------- -- <br /> ADDITIONAL COMMENTS-----=---------------.._--------------------w `---- <br /> �o. JN , = <br /> 3 ' <br /> ------------- -----------------------=-------------- ----------- <br /> -------------------------------- ------ -- --=------------- V� <br /> - -- --- - -- --- <br /> Final Inspection'bY:=----- ---- - -- -- - ------- - ----------------------------------- -----------------------------------Date : .=—Y------..._-._. <br /> t EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7176 3M <br />