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/ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ' <br /> ---------------------------- (Complete in Triplicate) Permit No. <br /> -----------------I- <br /> --- -------------- ---------------"----- � <br /> -------------------------------------------------------- <br /> - F' This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the4Sanoag lin Vb aljHealth`District for a permit,.to construct and install the work herein <br /> described. This application is mae ire dcoinpliance with`County Ordinance No. t4'9 and existing Rules and-Regulations: <br /> P ' <br /> JOB ADDRESS/LOCATION _VIL'.44 -- - ----- - -- -------CENSUS TRACT __------------------------ <br /> Owner's Name '' �= ' - -------•-------------------------- Phone _A41- -/-Z 7-7 <br /> v !s <br /> Address -------I�-------- -S•------------------------------------ ---• -- Litt <br /> I :,E w,_ Phone <br /> Contractor's Name iM - -- rcense # T� <br /> Installation will serve: `Residence Apartment House'[] Commercial ❑Trailer Court ,❑ <br /> Mote_00 ther-- --------------- ------ <br /> Number of living units:._________ Number of bedrooms Garbage Grinder ._ ___-_ _ Lot Size. -- --------------- ---- ---------- l <br /> �j "T.Al --,. � --------=-- � -- Private <br /> Peat Sand Loam f <br /> Water Supply: Public System and name " _ �{ _________- <br /> Character of soil to a depth of 3 feet. 5and'❑ Silt❑ Clay ❑. ❑ y Glay:,L:oam;❑ ; <br /> Hardpan ❑ r"�dobe*©- Fill Materialpt <br /> __--ilk-1--______ ---- <br /> {plot plan, showing size of lot,]Iocation of system in relation to wells,\buildings, etc. mustTle placed on-reverse side,) <br /> _ L,-f 1 <br /> NEW INSTALLATION: _(NoFseptic.tankor.seepage,pitipermitted.if public s'e'rver is available within 00 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] i ize---------- ------\------ __--_•- ---------- Liquid NDepth ---------------- ----- ; <br /> Capacity -------------------- Type _E_ ---Material-------N_.- - No. Compartmen#s <br /> ff -•--------------- <br /> Distance` to nearest: Well __�___________________3E___#------Foundation -_--________-_______.Prop. Line _________.__:____-___ j <br /> LEACHING L"•INE4 `,] No. of Nines ____________ __ _ __ Length of each line---- _--—------------ Total Length __-.__-_-_____...___--------------------- <br /> 'D' Box �------- __ <br /> ___ Type Filter Material ______________ pth Filter Material _____________-_-__ <br /> --------�. I ------- <br /> `= .to"nearest:`Well------ "`- __--__Foundation ------------------------ Property Line ---------•---•----•----- > <br /> SEEPAGE--PIT [ii.}� Depth Ce�__________________ Diameter -----________.Number` •_____i -_1-_________ Rock Filled Yes '❑ No C <br /> .tr <br /> Water Nble Depth -------------------------------------- _Rock:Size --�----------------------------- <br /> Distance.�to nearest: Well '----=------------------------- ------Foundation I------------------- Prop. Line ------------- <br /> I i ! <br /> REPAIR/ADDITION(Prev. Sanitation Permit Date <br /> Date __________________________________ <br /> lY encs) -Ep _ r 1 <br /> , <br /> Disposal Feld (Specify <br /> Requirements) -------------- ----------------- 6 -- {{ ---- ------ ----------- <br /> ------------------------ _,�l-------- ------------------------------------------------- I------- ----------[---------------------------------- --•--------------•-- <br /> } ---------- = _ =—-------------------------------—----- ------- <br /> i (Draw,existing and required addition on reverse side) <br /> I hereby certif -that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> rdi <br /> County Ordinances; State Laws,!�and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the'following: <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 <br /> as to become subject to Workman s Compensation laws of California." <br /> Signed ----- - - --------- .-- ------ . �- -- --- - - --------------------------------------- Owner <br /> ---- --- ------------------------------------ -title ------------ ---------------------------------------------- <br /> By <br /> t (if other n owner) <br /> t _.--_FOR D PARTMENT. USE ONLY <br /> ------------ <br /> - DATE <br /> APPLICATION ACCEPTED BY _. „ <br /> - <br /> NG <br /> ADD�ZONAL COMMENTS PERMIT <br /> ISSUED---------�- --------------------� ------ -- _ DATE <br /> f --------------------------------------------------- 1------------------------------------------------------------ ----------------------------------------------------------------------- _ _ <br /> ------------------------------------- ---------------l ------------------- <br /> S =- ----------------- - <br /> Final Inspection by: --- ----__-----.Dat 0 - --------- <br /> ---- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />