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� v FOR OFFICE USE: � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- -- �� � <br /> (Complete in Triplicate) Permit No.- <br /> (Complete <br /> Date Issued__. _ '-3—_7 <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 /> ' S /pS " C : ENSUS TRACT <br /> JOB ADDRESS/LOCATION----=----- --- =---- <br /> �, , s � : <br /> Owner's Name---------------------------------------------- 9 <br /> � '- -- Phone_ <br /> -----------Address' ------ 52 e,6.S._. ' S --- ----- - City -d/ . Zip---- •- -- <br /> Contractor's Name ; _ License #-----------Y----------------Phone--- - -------------- <br /> --------------------_. . . .. .r , _ ., ..¢ <br /> Installation:will serve: i Residence E] Apartment House E.] Commercial E] 'Trailer Court ❑ <br /> .. t <br /> Motel ❑ Other------- _ . .i <br /> Number of living units:----------------Nurriber.of,bedrooms'-.-____-__Garbage Grinder------------Lot:Size__ -------------------- <br /> Water Supply:.Public System and name.::...:.. ....::.: .:. ..::.. :...... .....'---.------------.----------=------------.- ----------- Private ❑ <br /> Character of soil. to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ . Peat Ej Sandy Loam ❑ Clay LoamEl <br /> Hardpan ❑ Adobe r] Fill Material-------------If yes, type----------_------_------_______- �. } <br /> (Plot plan, showing size of lot, location of:sys em in reation to s, buildi gs, etc. must be placed on reverse side.) ° <br /> NEW INSTALLATION: ''(No`�septic tank or seepage it permitte. ,if publi[ sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) ----SEPTIC-TANK ] /` ze---.'-- - -J--------------------------- `----_Liquid Depth..------------------ <br /> ---- - <br /> 4 L r <br /> G• y �. . . -Eapaeity.._.__+::___-;_ -Type----- ; --------- Material t}'FA == - No. Compartments <br /> stale]__- ---, 3unda�on - Prop. Line ; <br /> LEACHING LINE; } NotofcLines_eare ' L ngth ea lin®. Q_____�_�otaI Length._ �'__�____________t__ <br /> D' Box._' __.. ... <br /> FIter Mat al_l �__- Dept Fid r Ma�rial__'_ - - -.----------------/--- -----------�_-� <br /> Z <br /> Distance!to nearest: Well._ �------_.__.Foundation __ ._�___-___.Property Line.--------_ ____ ___.____0 <br /> SEEPAGE PITY � Depth____ ___________ <br /> _ Diameter_ --- <br /> - ._ .....Number {__:_____ � � i <br /> E ] p __________.�_ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth. _ __ __1 _ ______ ------ Rock Size-----.--- - <br /> :_Faundatiori Prop.--L--i-n--e--.------------- <br /> ine---- ---- -- -------- <br /> Distance.to nearest: Well ` _ _ y <br /> REPAIR/ADDITION (Prey:Sanitation Permit#._;_. : . _ <br /> �, ++�4 S - --------:Date-- ------------------ ----) # <br /> Septic Tank (Specify Requirements)--------- ----- - ------------- i -' ---------------------------------------------------- <br /> ----------- <br /> --- <br /> Disposal Field (Specify.Requ.irements)----------------------- -- ------ -- --------------- -------- -------- --------------------------------------------- ------------- <br /> ( <br /> F --------------- ------------ s ------ � - -- <br /> _ t <br /> ( �.� --- ------ _ - ------- ------- ------- ----------- -- -> - ---------------- ---------- <br /> '1 (Draw xisting and required addition n reverse side) <br /> I hereby certify that'l have prepared this application and that th 'work ill be-done in accordance with. San Joaquin County <br /> Ordinances, State Laws; and Rules•and ReWatickl mfrthe San Joaquif Local Iealth District. Home owner or licensed agents <br /> signature certifies the following: <br /> k "I certify that in the performance"of the work for which this-permit is issu d;•I shall h`t employ any 'person in_such manner'as <br /> ltog - sof California." <br /> .. -- ----- f <br /> .. ---a „ - .�----------- � Owner � � l <br /> Signed me ,subject.to W kman s Com ensa ion law". "" "" "^ � <br /> I p <br /> Oz✓ � <br /> ». BY ---- ---=- -- _ = <br /> Title <br /> (If other than towner) ` <br /> FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED BY i .y DA .----- 7 ---------- <br /> DIVISION OF LAND NUMBER `� - C <br /> --------------- -�DXTE----- 777777� ;------ <br /> iADDITIONAL COMMENTS-----=------- -------7---------------------------------- -------------------------------------- ---- --I- ------------------------------------ --------- <br /> ----------------------------------------- <br /> -------- <br /> 1 ------------------------------------ -- - ---------- -------------------- " " -------------------------- -------------------------------------------- ---- - <br /> ----- ---- --- ----------- --------- - -- <br /> = lFinaInspection b � -- --- ---- --- ---- 7----------- <br /> EH 13 24 SAN JOAQ IN LOCAL HEALTH DISTRICT Fas 2€677 REV. 7176 3M <br />