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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ r� <br /> ------' ®----- ----------------------------- pTriplicate) Permit No: <br /> (Complete in <br /> This Permit Expires 1 Year From Date Issued Date Issued _.. <br /> - <br /> ------------------------------------------------------ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance : <br /> �nance No. 549 and existing Rules and Regulations ' <br /> qp)oJOB ADDRESS/LOCATION -----------�_ ----_ __G0-aa-ol,_ -,k a&a, ---- A---------------CENSUS TRACT --- -- .-------.-- <br /> Owner's Name ------------------ -Gf2__ UG�------------------------------------------------------=-------------------Phone -------------- <br /> Address ----------------------------------------`�'�'��' ------------------------------------------- City --------------------------------------------------- <br /> Contractor's Name ------------ --- --- ----------------------------------------License # ---------:-------- ----- Phone ------------------------.----- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> t <br /> Motel ®'Other --- 4Wil lk?w-e-._______ <br /> Number of living units;-----/----- Number of bedrooms ----- -----Garbage Grinder -------� Lot Size -----&')D__&________-_______.______ <br /> Water Supply: Public System and name ------------------------------------------------------------------ -------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt]] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom.1E] <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) <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ Size------------2eo_ ------------ Liquid Depth _---- _______________ �a <br /> Capacity 1 cgo,_ Type P�A- -_ Material___ - _ No. Compartments NJ <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ____----____-___._____ <br /> LEACHING LINE [ ] No. of Lines ------9-------------- Length of each line____________ --------- Total Length --_,<9!P_____-----..__ <br /> n A r <br /> 'D' Box ;T-)----- Type Filter Material A ------- Filter Material ____1 ___________________________ <br />- -�— ^^ Distance to nea�est�Wel1 �________�"FaundationLine ---_____________________ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter _____________ Number ---------------------------- Rock Filled Yes ❑ No .i❑ c <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ..................... <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date _______________________________._) 1 <br /> Septic Tank (Specify Requirements) --- --- ----------------------------------- ------------------------------------------------:---- ------------------------------------------ <br /> Disposal <br /> ------- ,---------------------•- --Disposal Field (Specify Requirements) ------------- ---- ------------------------------------------------------ f <br /> ----- - --- -- ------ ------------------------------------------------------------- <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 <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Ilcen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issuedr I shall not employ any person in such manner <br /> as to become su . tt Wor n's C pensati.on laws of California." <br /> Sign , ' <br /> /OV7�--- Owner <br /> BY ------------------------------------------------------------------------------------------------------- Title -------------------------------------------- -------------------------- <br /> (If other than owner) <br /> FOR DEJPARTMPNT USE ONLY <br /> APPLICATION ACCEPTED BY1 <br /> -- ---- -- - - ---- - =----------------------------------------. DATE ----��--,f`-��---- -- ----------- � <br /> BUILDING PERMIT ISSUED .-- -- - ------------------------------------DATE -------------------- <br /> ADDITIONALCOMMENTS ------------------------ ---------------------------------------------------------------------------------------------------------- --------------------------- <br /> -------------------- ------------------ --- ----------------------I-------------------------------------------------------------------------------=------------------------------------------------------- <br /> --------------------------------------------- ------------------- ------ ------------ /3� ------------------ <br /> Final---------------------------------------------- --- <br /> Inspectionby; - - -- -------- ---- - ---- --- --- --- -------------------------------- -- -- -------Date ----- - - --- <br /> SAN JOAQUIN LOCAL HEALTH TR1CT <br /> E. H. 9 1-'b8 Rev. 5M, J <br />