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FFOR OFFICE USE: <br /> OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------ <br /> (Complete in Triplicate) Permit No.__ _,___� Lf <br /> ------------------- ----� -�--`------------- ---- <br /> -­--------------- ---- <br /> ------------------- This Permit Expires 1 Year From Date Issued Date Issued---_-"_"-2"--7,P <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstruct and install the work herein described. <br /> This application is made in compliance with County Ordinance No.549 and existing Rules and Regulations: <br /> t nn <br /> JOB ADDRESS/LOCATION------ a ;�------e------ _ -- . - - '1y_`--------------- ---------------.CENSUS TRA4i�_,fr4l-__ _ <br /> Owner's Name - <br /> p - - -------------------------------- --------------- ------------------------------Phone---- <br /> Address c _ ---------- City ----- ------ ------------------------ Zi <br /> P-------- ------------------- <br /> ------------------------- <br /> Contractor's Name---��_��- _ J?`ea,.�/9,c�-____C,�---------------------LicensePhane__133KFJs'•3 <br /> Installation will serve: ResidenceE�'�Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------ ---------------------------- <br /> Number <br /> ------------------- -----Number of living units:--------- ------Number of bedrooms___%.3----Garbage Grinder------------Lot Size----- .."__-____-___._______________ <br /> Water Supply: Public System and name---------- ------------------------- ------------------------ ---- ---------------------------------Private jj;,- <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 /> i i <I <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [,�� Size____� �R�____1� __l-� Liquid Depth_:c_ ____ <br /> Capacity_li;d4r�Type__04 _------Material_6� s. -_No. Compartments__-.-21_______________________ <br /> Distance to nearest: Well-----� ______________:-______Foundation___� .-___________Prop. Line._�_�______-__-___. <br /> LEACHING LINE [4-r-No. of Lines_____________________.Length of each line._ __ f---------__-_.Total Length.:__ZS!;71_ __________________ <br /> ___ 7 <br /> D' Box_ y__Type Filter Material/_"7_/ -Depth Filter Material____2-_r--------------------------------------------------- <br /> Distance to nearest: Well--Ie- --- ' ----------- <br /> � Line- <br /> ;;4 <br /> - -Foundation- Property Line ------------------------------- -- <br /> Depth-�___._____ _ erl_�l_L _.___Number---------- __.______________ Rock Filled Yes 8,.—No <br /> Water Table Depth-------112O <br /> -----------•--------------------------------Rock Size--------------- <br /> Distance to nearest: Well____--- ________________________Foundation_ r. r�� �rop. Line---�a.3__._______. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__-___________________________-___________-__.Date________________________________-____._____) <br /> SepticTank (Specify Requirements)---------------------------y--------------------------------------- ------------------------------------------------------------------------------ <br /> Disposal Field(Specify Requirements)--------- - -- --------------------------------------------- ------- -------------- -------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 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 t7WorkK an's Compensation laws of California." <br /> Signed-------- --- OwnerBY------- -- -� -- -- -------------------------------------------------Title_�Cl2l�---`-----'-'�---— <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY____ __ _________ -- - --- DATE _----- ____'"_ ___ '______ <br /> ---------------------------------- <br /> DIVISIONOF LAND NUMBER------------------------------ -------- -------------------------------------------------- ---.DATE--------------------- ------------------------- <br /> ADDITIONAL COMMENTS - - - - <br /> ------------------------------------- ---------------- ------------------------------------------------------------------ ----------------------------------------------------------- --- ---------------------- <br /> -------------------------------- --------- <br /> - ---- <br /> - --- ---- -- ------------------------------- <br /> ------------- <br /> ------------------- - - -- --------- <br /> Final Inspection by: - ;, f/ ---- ------Date---------- --- "`-- < - - <br /> EH 13 24 SAN J QUIN�EALTH DISTRIC F&s 21677 E�/76 3M <br /> T <br /> CIO <br />