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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> . ......................_.............----..... <br /> _ c <br /> (Complete in Triplicate) Permit No....................... <br /> .............................................. <br />� Issued......'.. .......... <br /> •••--•--•-•••--••-•--•---•-•-•--------------------------- This Permit Expires 1 Year From Date Issued pate <br /> Application is hereby made to the SaniJoaquin 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. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION. 02.4 t f = -...: .....:: : ...:.......CENSUS TRACT---.:_: .-•-----•-•- •....... <br /> # . <br /> Owner's Name..... e��r +�lf�.".. f4 ------ r �.. = - Phone. ------------------------ <br /> /5 <br /> is ` <br /> Address cGO--.. .. - :.CityoClG.i �a ....... Zip.�G- .-......_.. <br /> /5 C,r-- r <br /> Contractor's Name.-.. C t�.0 .t.�l .-------�.,.^/3t.�tkkL C-'/A�t/-_----------License #-- c. �------Phons.�pf-- <br /> Installationwill serve: Residence ❑ Apartment House.E3 Commercial 1-4 Trailer.Court ❑ <br /> Motel ❑ Other-------------------- - <br /> Number of living units:----------------Number of bedrooms------------Garbage Grinder............Lot SizeJ. X..41To..._._-...-._...-.._.... .... <br /> Water Supply: Public System and name---------- ---------- -------------------- Y= ------- I ' ll f—-------------------------•-•--- ------:Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ . Silt 0 Clay..[j Peat ❑ Sandy Loam ❑ Cloy Loam ❑ <br /> Hardpan❑ )Adobe ❑ Fill Material..-.:._' ...If yes, type----=---------------- <br /> ----------- <br /> {Plot plan, showing size of lot, locationlof 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 ovailable.within 200 feet,] <br /> 1 F <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ ] �i�e..:- �� .---... l-- W----------------Liquid Depth.---_.---..- ---.---------)J <br /> Ca .04.pacity_ 0......Ty.pe.eA&O&AMcite:ial... ! :.No. Compartments.-.----LM?,--------------------- <br /> Distonce'to nearest: Well. :----- --------- --.Foundation..: .. .... .... _--- Prop. Cine__ <br />` LEACHING LINE . [ ] No. of Lines......f----------_----- Length of each line...... �_..--------- Total Length...- � ---. <br /> / / <br /> D' Box../.:....Type Filter Matericil./X eZaDepth Filter Material-------I-e-��............................................. <br /> Distance to nearest: Well-_.._.s' G-- d <br /> --_---.:Founation.- ----------------Property Line-{ . - -.----...---------:- .. <br /> SEEPAGE PIT :f <br /> [ ) Depth.� .....Diameter. -3..........Number........_ ................... Rock Filled YespS, No < <br /> Water Table Depth.------------------------------------------ Rock Size.1/ r t <br /> - ,_r., .��. <br /> Distance to nearest: Well.. /V ...................Foundation...-4- .7..........Prop. Line_._�p............... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#:_------- ----..--.---._...--.__.._----_.Date----------------------------------------------] <br /> Septic Tank (Specify Requirements)------ =---------------------------------------..:----------------------...-............ -----7------------------------- <br /> Disposal <br /> -----•-------------------•--Disposal Field (Specify Requirements)...�- ----------------- `--- . ,:... , ---------- ----------------------------..-------------- <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 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 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 Workman Compensation laws of California." <br /> Signed ----=----- ..Owner <br /> g ' -� <br /> r' �, .rte : . - <br /> y...- ....--- --------'.Title ---------------- ------------ ---------------------- <br /> .......... <br /> other than owner) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------------------------- - - y DATE:-.. 6_-3/-/(? - i <br /> DIVISION OF LAND NUMBER----------------1- • .-----.DATE-----..._..---------- ._ <br /> ADDITIONAL COMMENTS_ -I.... . .. <br /> v� �% <br /> -- „' <br /> ------- ------ - --- <br /> Final Inspeciion b -=- -- = = -----•. ---•-- -- ----.Date.---- i� l ... . ------ <br /> E" " 24 SAN J AQUIN LOCAL HEALTH DISTRICT Fss s'°" Rev. rna a�n <br />