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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT . gsV <br /> ------------------------------------- <br /> . . ._ <br /> N ._-�- __ _ <br /> � (Complete in Triplicate) Permit _ � ----- <br /> --------- ----------------------------------------- ----- � 7`� Date Issued.7.:��'� <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 a sting Rules and Regulations: <br /> JOB ADDRESS/LOCATION .�7�- -- --------- - - res:� ------------------ CENSUS TRAtCT�.----- ------------- ---f--- <br /> Owner's Name Q�i'L -- - ---- Phone" �7f <br /> Address-------lc; - - Z1P <br /> Contractor's Name-------------- -- '__a---"4.''Cicense #62X ° SP3---------Phone_- ---- <br /> c <br /> Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court El <br /> Motel Other-- --- '------=------------------=-------- , <br /> ❑ . �.__ Garbage G inder--.- ------Lot Size---- •----------------- <br /> Number of living units:-- __-_'_ _ Number f bedrooms.. . g ,r <br /> Water Supply: Public System'and name_ _ <br /> / - : --------------- }Private ❑ <br /> Character of soil to a depth of 3 feet:" ,Sand ❑ t n Clay ❑ Peat ❑ Sandy Loam ClayLotxm <br /> Hardpan E] Adobe.❑ Fill Material-------------If yes, type------------------------------- <br /> _.m.. <br /> (Plot plan, showing size of lot,location of system in relation to wells, buildings, etc. must be placed on reverse side.) rtw <br /> NEW INSTALLATION: (No septic tan-k or see. age pit permitted if public sewer is available within 200 feet'j 1 <br /> J�a pp I <br /> PACKAGE TREATMENT [ ] : SEPTIC TANK ----------------------------- -----Liquid <br /> I Depth_- 5r------------------ <br /> ------- <br /> ------`_No. Compartments------'�-------------Capacity-L34 ----.:Type . - Material <br /> l <br /> 4 <br /> ' r Distance to nearest: Well . ---- =- <br /> - <br /> / . _. Fodation________________________ Prop. Line------------------------- <br /> LEACHING <br /> ___���______-. <br /> LEACHING LINE., Len ofAealins ---------------Total Length ------ D---------------_---.-No, of Lines "FtD' Box_ "TypeMe , <br /> , <br /> Distance to nearest: WeII_- __Foundation__- l.2 -----------Property Line-----__.-/4--- _-_--._ <br /> N ❑ -� <br /> �' -��"'�_'--�' � ____-_ Rock Filled Yes No = <br /> SEEPAGE PIT [ ] De th_�--.-----_-_--Diameter-------------- ----- �►tuber--=------:---------------- <br /> Water Table Depth-- - ------- -------------Rock Size--------------------------- ---------------------- <br /> 1 <br /> -Distance jq.nearest: Well-..--...----------------------------- Foundation----------------------- ---Prop. Line--------------------------- ! <br /> REPAIR/ADDITION (Prev. Sanitation Permit#......____._............. _________________a�;_._.-:Date____..__..--.-----_ ___,____________..__e_) <br /> Septic Tank (Specify Requirements)------------ -------- -----------------------------------------------=--k-------= <br /> = ------------------------------------------------=------------ --------- <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 'th perforniinnce of the work for which this permit is issued, I shall not employ any person in such manner•as <br /> to becomY7AL, <br /> bject t Workman's C pensati laws of California." <br /> Signed ----- -- --.------- - --------- <br /> Title_._. -------- <br /> - - - <br /> (If other than owner) <br />�- FOR RWRTVN74SE ONLY <br /> APPLICATION ACCEPTED BY_________________________ __ <br /> DATE. ---- ------ <br /> DIVISION OF LAND NUMBER._ .-.... ------------------.DATE.--- -------------------- ---------- <br /> ADDITIONALCOMMENTS-------------- -- --------------------------------------------------------------------- ------------------ -------------------------- -------------- ----------- <br /> -------------------------------------- <br /> Final <br /> - --- -------------------- --- <br /> FinalInspection by:-- --------------------------------------------- -------------------------:------------------ ---- f`------Date ------ - 7 = ---------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DI T F&s 2167 7176 3m <br />