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FOR OFFICE USE: ,/ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> . <br /> (Complete in Triplicate) <br /> Permit NoZgo:-1/l. _.. <br /> --------•••---------• <br /> Date <br /> ................ 2 :� 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 /> a <br /> JOB ADDRESS/LOCATION ._... ..� =' l!._ Zl- --- CENSUS TRACT_----------._ -".-.----.-- <br /> Owner's Name.... ... . . .......... Phone_ <br /> -- <br /> � ��. _: --- <br /> ell <br /> C Cit �_ �:: 4�.L ..... Zip-------------------_-------- <br /> _Address �_ ` Y <br /> y C Phone. ../ <br /> r , r.� ?�-- t.• f .. �. . <br /> Contractors Name.. --- - �. .. - C . -•.i :.�--- ---- .._.. License .- / w - <br /> Installation will serve: Residence 2---- <br /> -'Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- - _- <br /> Number of living units: _.. --/---_.--Number of bedroom s._3.... . Garbage Grinder-_�f'�: :�-Lot Size - <br /> Water Supply: Public System and name__._. ---- - --------- ------------ ....... -----------_-------•----•--•------- --------------------------------Private <br /> Character of soil to a depth of 3 feet: SandClay ElPeat EJ Sandy Loam Q Clay Loam El❑ <br /> Hardpan E] 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,) W <br /> PACKAGE TREATMENT [ j SEPTIC TANK [ j Size --.._. _-.._---.----------------------------------------Liquid Depth........ -------------_ <br /> Capacity_--- ------ -- ---Type--•--•--------- ......Mate-Tial---------------_---.--.-No. Compartments----- _------ 1 <br /> Distance to nearest: Well_...............-------._---_--------Foundation.-_---__ - ...___ .. Prop. Line---.-----""--- _-------- <br /> LEACHING LINE [ j No. of Lines __..-.....................Length of each line.__.--._..__... --------- ---Total Length _ _...........---------.......__-.- <br /> 'D' Box........... Type Filter Material........ ...........Depth Filter Material------------- ------------------------ ------------ -------- <br /> Distanc&to nearest: Well-----.--------- ----- -----.Foundation--------------------------."Property Line.......... _......------------ <br /> SEEPAGE PIT [ j Depth---------- _----Diameter..............._----Number-------------------------------- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth----------___---_---------- ..................Rock Size......_ .....------- ------ <br /> Distance to nearest: Well.....-...... Foundation----------"---- -- -- Line.---------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__.__-___.----------------------- ------------•--Date------------------------------------- ------) <br /> Septic Tank (Specify Requirements)------ ----- -"" " - -----------.__. ' ` -- "" - <br /> o <br /> Disposal Field (Specify Requirements).- `-C - •. • - r J --� -"•"" " " " - " - <br /> - f � - -------------•----_ ........ -------- .......... <br /> ( z <br /> f. f e <br /> -----•----- ------------- --------------- ----- "---- --- -------------------- - .............. ----- -- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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--------- ------ ........ --................ ---...__Owner _ <br /> 1 - �/ -=t Title----- -� --- `---- ---- . --._-------------- - <br /> (If other than owner) <br /> OR.DEPARTMANX USE ONLY <br /> APPLICATION ACCEPTED BY------- -------- ". . -- <br /> - ........... -- ..... ----------------------"---- -DATE ---" - --a- -l.p..- -. .._-- ----- <br /> DIVISION OF LAND NtLIMBER_---------- -- ------ - ---- . ----•-----... ---•- ------. DATE . --------•--- -------- --------- ------ ---- <br /> ADDITIONAL COM/ NTS... <br /> -- -- ---.. <br /> •----- ------------------..__.. <br /> --------- -------- - - - <br /> Final Inspection b1-t7�. - ------------------ -------------------------------------------------------- Date Z- Z - ._.. <br /> Y <br /> Fos 21677 Rev. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT /�a inn <br />