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� e <br /> FOR OFFICE USE: APPLICATION FOR,SANITATION PERMIT FOR OFFICE USE: <br /> --------------------------------------------------------- N nn <br /> �• Permit No._9__'t_'-5 f <br /> --------------------------------------------------------- � (Complete in Triplicate) <br /> Date Issued---b/lZ�f9_ <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 /> LC —' <br /> JOB ADQRESS/LOCATIO - ------ --- - CENSUS TRACT---- <br /> Owner's Name--------------- -- ------ -------------- Phone--------------------------,--1,--- ---C' 1 <br /> ---------Zip-----_ <br /> Address--------------------- - �.O---L1 ----------- ' - � <br /> -GtiL, Z7--&. <br /> Contractor's Name , c �D- - License #- 2f--- -Phone-------------------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ ComM7 al ❑ Trailer Court E]/ Motel F-1 Other- �,.:Q._-KGs-— a r____ <br /> Number of living units:-_-__(-_____Number of bedrooms__r2_____Garbage Grinder------------Lot Size_______________________ ------_____..______________ <br /> Water Supply: Public System and name .--------- ------------------------------------- --------- ------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand [I Silt EJ Clay E] Peat❑ Sandy Loam J�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 see age pit permitted if public sewer is available within 200 feet,) / <br /> s� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size__ _________________________liquid Depth___ _______________ <br /> Capacity-�n?s-^'----------Type. -- Matarial.�- -------No. Compartments------- .----- --------------- <br /> Distance to nearest: Well_____Y.__.__ p._ -__ ____.________Foundation-------- � --- <br /> ---------------- <br /> Length .____L _o__._____________.___ <br /> 'D' Box_.__l----Type Filter Material------_--'__/2------Depth Filter Material--------f9------------------------------------------------- <br /> D i sta nce, <br /> ---._------ ------------------------------------Distance,to nearest: Well----------- --------Foundation---------- _?------------Property Line_______S______.__-____ <br /> SEEPAGE PIT [ ] Depth------------____Diameter_------------------Number-------------------------------- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth-------------------------=-------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Well_ __________________________Foundation--------------------------Prop. Line-------------.____________ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--________________________________________________Date-______________-___________________________) <br /> SepticTank (Specify Requirements)---------------------------------------------------=----------------------------------------------------------------------------------------------- <br /> DisposalField(Specify Requirements)---------------------- --------- ------------------------------------------------------------------------------------- --------------------------- <br /> --------------- -------------- ---------------------- ---------- ------=--------------------------------------------------------- ------------- ------------------------------------------------ --------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that l 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's Compensation laws of California." <br /> Signed-.------------------------------------ <br /> 4- <br /> BY--------- Owner <br /> - ----------- <br /> --- 'p �e <br /> ----- ----Title---- --- �jiel14-------�------------------------------------- <br /> (if <br /> ---------- ----- ---------------- <br /> (If other than owner) <br /> R DE RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------C '--- - - --------------- ----=-----------------------------------DATE.' ----- ----------------- <br /> DIVISION OF LAND NUMBER-_---- --------------- --------------•----------------------DATE------------------------------ ---------------- <br /> ADDITIONALCOMMENTS----------------------------------------------------------------------------- ----------------------------------------------------------------------------------- <br /> ------------- - - - - <br /> -------------------------------- -- --- <br /> -- <br /> ----- -- ---------- ---------------------------------------------------------------------------------- ------------- --- <br /> - ------------------- <br /> Final Inspection bY:------- ----- '�-- --- - -- ----------------------------------- Date----- <br /> ------ - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M <br />