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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- ............... ------ <br /> (Complete in TriplicatePermit <br /> -------------------•-------------- :1f---- f I Date lssued...r :* <br /> I!..... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to-t a San Joaquin Local Health District for a pe rmit to construct and install the work herein described. <br /> k This application is made in compliance with County Ordinance No. 549 and existing Rules`arid Regulations: <br /> !OB ADDRESS/LOC ION.. ....._ `: CENSUS TRACT.......-------- ----- ----. <br /> Owner's me. ! r'` q ..... .... -------=--- -- --- ------ -------------=- ---• -•---- ..... Phone-- - .. ." -- <br /> City `` AA-3I Mw.. .... zip "3 <br /> ----- <br /> Address-- --- or-- .�:�--. -.--If-- ------ ------------- --------- • ----- -...-_......-- -�:�- <br /> I <br /> Contractor's Name_ ................. --•---. .... <br /> License #-----------------------------Phone............... ------------ ----- <br /> Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- "---- --- -----------...................... <br /> Number of living units:.......I .L-Number of bedrooms...5- Garbage Grindar._.. <br /> Lot Size.. ... ` .----=--------- <br /> IM <br /> T �1.i�-� .-..Private ❑ <br /> Water Supply: Public System and nameV.- �t^�--_- - W.71* Ole- r ` a - --------'- - <br /> i Character of soil to a depth of 3 feet: Sand E] Silt El Clay E3 Peat E] Sandy Loam Clay Loam E]k Hardpan ❑ Adobe ❑ - Fill Material....... _ ..If yes, type------- t <br /> Plot Ian showing size of lot,-!location of system in relation to wells, buildings, etc. must be placed on reverse side.). <br /> I j p g I' ...�- <br /> i <br /> NEW INSTALLATION. (No �s ptic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ .� SEPTIC TANK j74 Size------- ---------------------- • ------ Liquidp --- <br /> Capacity.-I� ---------Type--....---- Material --------------- ..---No. Compartments.-----=- •----- ------- - -------- <br /> • �M tY--------- . - �. . <br /> fDistance to nearest: Well. '.----••----------- -- -------- --....--.Foundation.:--- .... . _.-_..... Prop. Line.---- -- --- --------r <br /> i it <br /> LEACHING LINE [ ] No. of Lines---------------------------Length of each fin e.__:----------------------_..Total Length <br /> 'D' Bax......--. ..Type FilterMaterial.............-..e...Depth Filter Material................... <br /> ------------------- <br /> kDistai7ce to nearest:Wei l---•.----------------------Foundation---- ---------Property Line------.------- <br /> -- r Rock Filled Yes ❑ No ❑ <br /> SEEPAGE PIT [ ) ---- <br /> Water Table Depth--.-..----'---------------- --'--- -- ....----- ------------ --------- <br /> t Depth------ -...--- <br /> 'Diameter ;.,:-_: Number Rock Size <br /> i W hN • <br /> Foundation........ ...... ... ..Prop. Line----- ....... ....... <br /> t <br /> Dista Qrt: Well.-...... --�- <br /> . <br /> ....Dote -------------------- <br /> REPAIR/ADDITION {Prev. Sam-tation Pemit#---.-----•__ � -------.) <br /> ...... <br /> i <br /> Septic Tank (Specify Requirements)-------- ------------ F k �` .... ;-� ................--- ----------------- <br /> / i44 Wd <br /> Disposal Field [Specify Requir�ments)...-----4� 1 <br /> ----- <br /> 11 - -- -- . ---•------- <br /> ---.•---------------•---- <br /> I - ---- ----------------- <br /> d that the war will ,be.done m �accorda ` <br /> f [Draw existing and required addition or)_L_v_erse side) <br /> -.!�^j" nce with San Joaquin} County <br /> I hereby certify that I have p'epared this application an me owner or licensed agents <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health D.istrid.,HoHo <br /> signatu •fies the following: <br /> "1 ce ify that n t p rfor mance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to be 'o s <br /> ie, <br /> - rkt an's Compensation laws of California." <br /> h <br /> Signed--- ...-- -- -- Owner <br /> .---.....:�_.. .. ............ --- . <br /> s <br /> r - ----- ---- ----------- - ............. ------......... <br /> BY-------------------- ....-----• --i <br /> Title_ <br /> �µ {If other than owner) <br /> F R DE ARTME E ONL <br /> ` . - .'fi`''r` . ---- ..............•DATE --- --- - .-S.. ... -- --- .------. <br /> APPLICATION ACCEPTED BYI�-.---- <br /> DIVISION OF LAND NUMBER`-------------- - ---- .....-�"` ., ---- ..... <br /> -- -------- .-.-DATE--------- -------- --- --- -------------------- <br /> ADDITIONAL COMMENTS. '... T ........ ---------------- <br /> I - <br /> I�I -..r <br /> --------------- = ---- .......------- ----- ------------------ <br /> . . <br /> I�i .. ...............•----- r..._ <br /> •- --... ....-.......'. ....-j&�� <br /> --- 1� ...------ .Date.------ . - .._.-.---- <br /> Final-Inspection b --- --- ..Y <br /> F8 21 REV. 7176 3N <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT..-- <br />