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+r <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------- --- -- -------------- <br /> (Complete in Triplicate) Permit No.=_ ���_---__ <br /> --------------------------------------------------------- <br /> Date <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 /> JOb ADDRE55/LOCANT O C -S------ _ --- - --------------------- --CENSUS TRACT----- -------------------------- <br /> Owner's Name L(/ `�-- -----=------`-----=---------------- Phone--------------- ------- -------------- <br /> •�k� �`� T_ -- '�` 'Address >; . City ----- - -- Zip <br /> -- --- ---- -- ------------- <br /> _ <br /> Contractors Name-=_ --- ---------'.--�- -- ---------------- ---------- ----- --------------' -'- -.License #------,�`� �� ' Phone-- <br /> Contractor's ------ <br /> Installation <br /> Installation will serve: Residence ❑ Apartment House. Commerce I ❑ Trailer Court ❑ s <br /> t <br /> _.Motel El- Other,Other ---- --------- <br /> ' <br /> Number of living units------------------Number of.be'drooms------------Garbage Grindar__.;._._.-----Lot Size----- -----_._.__----------------- <br /> Water Supply: Public System and name -'------------- --------------------------. -----. . -- - _- - ------------- . --------------:--Private <br /> i _ (. . _ 1 <br /> Character of soil to a depth of 3 feet: Sand ❑ Sil ❑ Clay E] Peat 7] Sandy Loom ❑ Clay Loom ❑ <br /> Hardpan ❑ Adobe Fil 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'tarik or seepage pitpermitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ['j Size-:----------------------- ----------------------'___-t-----Liquid Depth----------------------- <br /> Capacity------; =`- 'Type ----`-- ---------------Material---------------------------No-Compartments-------- ----- s -- <br /> ...Distance'to nearest:.Well------------ ------- - Foundation Prop. Line -------- <br /> LEACHING LINE' [ ] No. of Lines_______________ _ _Length of each line__-=__.__. ____ . Total Length .- ---------------------------------- <br /> .- <br /> f � Distance:to �earest: We -------- <br /> Filter Material. -_ __.____ :__.___ ___._______ - ______ ---`______ <br /> D' Box--- ..Ty Filter Mate fi-.. -_ <br /> .. _..., . - .. <br /> t - _ _-- .-- ---.Pr e--------------- <br /> t -Foundation operty Lin <br /> SEEPAGE PIT [ ] Depth------- __. __--Diameter-:------------- _Number- _________ ____ I Rock Filled Yes ❑ No <br /> WaterTable�Depth = ` ----------Rock Size-----'-- ---=-------------=----- =---------•-- <br /> lti # We � <br /> l <br /> _ = rProp. Line.---- --------------------- <br /> rmit aREPAIR/ADDITION (Prev: anitation P # <br /> Septic Tank (Specify Requirements)----j------------------ } _:_ --------- ------------------------------ <br /> �.� --------------------------------- <br /> Disposal Field (Specify.Requirements) <br /> ---------- - ----------------------------------------- <br /> cro- . .:. :-. .. -------------------------- <br /> - <br /> - ----------------- - <br /> l i -.---` <br /> I (Draw existing and required addition on reverse-side) ' <br /> I hereby certify-that I have-prepared•this application Iand that.the -wd-Ys will be done in accordance-with San Joaquin County <br /> Ordinances, State Laws,-and Rules and Regula:tioris of the. Sah-Joaquin Local Health District, Home owner or licensed agents <br /> t . , <br /> signature certiFies the following: g <br /> "I certify that in the performance of`the woik for which this permit'is issued; 'l shall hot employ any person in such manner as <br /> i ...�..�--.-.- ---- ���-s:of Californ`ia." <br /> 'to become. I ct..t Workman's ompensation:-law t <br /> 9 I - -~ Ow <br /> `�Si red-=------� - - � _ <br /> BY-1 <br /> 1 '• .G� Title ---------------------------------- ------ <br /> .t <br /> (If lier.`�tlian owner) <br /> .� ' <br /> t FO DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED BY------ µ ------------------------ ------------------------DATE.-o��---- =- ----------- ---------- <br /> DIVISION OF LAND NUMBER--------- --------------- � = DATE <br /> -------------------------- <br /> ADDITIONAL COMMENTS. ----------------------------' ------ ' <br /> ---------------------------------- ---------------------------------------------------------------------------------- ------------------------------------- ----- ------------------------ <br /> i --- <br /> .,.. ------------ -------- <br /> Final Inspection-by: - _ Date �--�� !-------------------- <br /> EH 1 <br /> ---------- ----- <br /> EH '3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. W6 inn <br />