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FOR OFFICE USE: FOR OFFICE USOd/_615 <br /> APPLICATION FOR SANITATION PERMIT <br />' ................................................ (Complete in Triplicate) Permit No <br /> ............ Date Issuec6_4 :.. <br /> ........................................ This Permit Expires 1 Year From Fate Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with Count Ordinance No. 549 and existing-Rules and Regulations: <br /> CENSUS TRACT.----- <br /> JOB ADDRESS/LOC�TtON. r _'. ...... .�... / .' ' ..,,�::_. �!f <br /> r <br /> 71 <br /> $ 'i ` v .Phone__..- --�--- iC <br /> Owner's Nome..._� '��.��;.�- --;-------� �'��`-.� r: �--:�`-- -�.'�-.-. ..... ........ � --- . �--- ..!,„: � -- ---- <br /> Address---------------- .�X `"" ark` -- ...._._...City...- � ,„�{ zip_.... :.. .. <br /> -- - L am' - '� <br /> Contractor's Name ”' r" : . ....... .�` .... --License # .. ': hone.� s .r-. .. <br /> Installation:will serve: ResidenceA Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------ ----- ----_ - <br /> Number of living units. .. <br /> .. ...Number of bedrooms._-. _Garbo e Grinde-r...I�''.-Lot Size... ._ <br /> w <br /> Water <br /> r <br /> Supply: Public System and name.... . ......... ... <br /> . .:...... ... . ----------------------------------- .-- - <br /> ----------------------------- ----------- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay Eg, Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill 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 tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> 4 � <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size..: --.�..__ _.�.- *- ------------ <br /> Capacity/.024)0- <br /> ------------ ------------Liquid Depth.-�- _- -......---.._..� <br /> --- .•- <br /> Ca acit /�) - ..-T --- ------------------- <br /> P Y -- --- - YP - :.� ��-----�--Material... --„•.,,.erc, `-�....No. �mpartments.---- jsN <br /> Distance to nearest: Well.... - ------------ ...........Foundation op. Line..-..-��.__�.. <br /> LEACHING LINE No. of Lines.---...�--------------Length o1{each line... �..�,_.,_-----.----.. --- Total Length.... - -- ..°--•-- --- ---- - <br /> 'D' Box � Type Filter Material. ;i-"�--�-�Depth Filter Mater ial.11-�---..-----••----- <br /> Distance to nearest: Well.. .-------....Foundation....- - .-- ....-.Property Line.-- ---------------= <br /> SEEPAGE PIT Depth. -.--Diameter. .#-�.---Number..... .................... �1 Rock Filled Yes No <br /> Rock Size._ - <br /> Water Table Depth. --- ------ ---------------- " ... .. <br /> �n Prop. Line.. ""�� <br /> Distance to nearest: Well... --------------------•. Foundation.._.., . -. . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------•--------_-------1............ -Date.....-------- --------- ------] <br /> 5eptic Tank (Specify Requirements)--..... ....... ..... ... - - ---- --------------- --------•--- <br /> ----------------------- --------------- <br /> Disposal Field (Specify Requirements)....... ............. - --------------•---- - <br /> ...--•--.----•-•............................ -------.................. -------------- ......I........ ------------------------ ........- <br /> (Draw existing and required addition on reverse side} <br /> 1 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 /> i ned...__-�� orkman's�Comsation la sof California.” - <br /> to become sub'ect to W�;.- caner <br /> ^-"-' ---------- <br /> f <br /> BY -*ter° .��'. ............ .Title---- .-" ...C4 .rt <br /> (If otherthan owner) -' <br /> FOR PARTMENT USE ONLY <br /> �€ ;-;- - .-IL� ..r�:. ."" DATE.- . .. '� .; • <br /> APPLICATION ACCEPTED BY._:__.. _ <br /> DIVISION OF LAND NUMBS&........--- -- ----. DATE . ... ---------- <br /> -------- <br /> ------ - <br /> ADDITIONALCOMMENTS- --------------_. _----------- ------ ...---_-------- - --------- --------.................... .........--._......_.. <br /> ------------------_... <br /> -------- ---------- --------- ----- <br /> ...----•-------•........_..._....,.- ----------------- --.-�, : : <br /> FinalInspecfion b ------------- ------------- -----------Date................... --- ..... .......... ....... <br /> E SAN JOAQUIN LOCAL HEALTH DISTRICT rss 21677 Rev. »>6 am <br />