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FOR OFFICE USE: f FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------- -------- ---------------- --------------------- (Complete in Triplicate) Permit No. �9S�h- <br /> rf <br /> Date Issued/1')=.3/- <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 ADDRESS/LOSATION---/Or_ i/1------ ----dl--------------------------------CENSUS TRACT f"�"�Z- <br /> Owner's Name--- ------------------- ------------- -------------Phone__- <br /> - ------------------------------------------ - - <br /> Address--- - -------- --- - - --- -- - - ----------------------------- -City_/��'� ` --- ------- <br /> Contractor's Name_ '� .� - ----License #_„�eSF'-�/ Phone <br /> ------------------ <br /> Installation will serve: Residence [, 'Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------------------------------- <br /> Number of living units:__ ______Number of bedrooms--- ---Garbage Grinder---_--------Lot Size___ a -------------------_------------_____ <br /> Water Supply: Public System and name------------- -- - ------------------------------------------------------------------------------------------- --------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ 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 /> 1� _ _ Liquid Depth =�__ e________-- <br /> f/ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [�� Size--- __f_--- - � - - q p <br /> Capaaty /__ yp � _____Material--- ---------- Co�partments �r <br /> T e- -- - <br /> r ff � ff / <br /> Distance to nearest: Well__ ____`_-L`v'___/__Foundation._.l__ ---________Prop. Line__ __ <br /> LEACHING LINE No. of Lines____ 9 ____Length of each line__ Total L�ngth _____ _ ___�________________ <br /> -mac -- -- -- ------ <br /> /�� ti <br /> 'D' Box��__Type Filter Material ____ �__ epth Filter Material____----------------____________________________� <br /> Distance to nearest: �V� I _�� 'Foundation___ -�__-_______Property Line-__ �- <br /> « � - ' - <br /> K [ ] p <br /> De th_� _ B+ eter--------------- Number------ -,2— Rock Filled Yes U_ No ❑ <br /> Water Table Depth-------- ---------------------------------------Rock Size--/-/"- ------ -/_-_ - ------- <br /> Distance <br /> -----Distance to nearest: Well---�%� �����---Foundation----144 <br /> Prop. Line <br /> REPAIR/ADDITION (Prev. Sanitation Permit#____________________------------------------_.Date__________________________----------------) <br /> SepticTank (Specify Requirements)--------------------------------------------------------------------------------------------------------------------------------------------- --------- <br /> Disposal Field (Specify Requirements)-------------------- - ---------------------------------------- - ------------r <br /> - ------------------------------------------------------------- <br /> ------------------------------------------------------------------------- ------------------------------------------------------------------------ --------- - ---- -------------------------------- <br /> (Draw <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 Count <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agerr <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 <br /> to become subjecto Wor an's Compensation laws of California." <br /> Signed--- -----------------------------------------------------Owner <br /> gY _ - --------------------------- - -----Title---G ,.. .. . - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED Y__-/ '— -_� DATE _ - '� f <br /> DIVISIONOF LAND NUMBER------------------------------------7 __ ____ ___---- --------------------------------DATE ____ <br /> ADDITIONALCOMMENTS-------------------------------------------------------- ----------------- -- ---------------------------------------------------------------------- <br /> ---------------------------------------------------------- - - ------------------------------- ------------------------------ <br /> --------- i <br /> ------------------- -------------------- - - - ----- - <br /> Final Inspection by ------ -- Z - -Date - <br /> EH 13 24 / SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7 <br />