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FOR OFFICE USE: <br /> FOR OFFICE USE: . APPLICATION FOR SANITATION PERMIT <br /> Permit No.-;;f'- ----3 <br /> -- ---------- ----- ---- - ---------- -------- -- [Complete in Triplicate) <br /> - -'--�_l <br /> ------ Date Issued--���?-7e <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/LOCATION._ :.7. _I--_ - <br /> } <br /> ._CENSUS TRACT -- =------------ '- .. <br /> Owner's Name ---- = -' f :. _ _ one <br /> - -- <br /> r� ., .. T -------- --------- ----- <br /> Address - c <br /> ----- -- - --- =- .-,City ,_, � Zip.---- -: <br /> ,.. ' <br /> __- License #_3zZ --Phone j <br /> Contractor's Name___ ." g----- - -- � -- - <br /> _ <br /> Installation will serve: Residence . Apartment House❑ Commeraidl,❑ Trailer Court ❑ <br /> ❑ Other - ;• - ------------------ <br /> Motel <br /> 7. �• ____ ._ - <br /> Number of living units ----- _--._____.Number of bedrooms'.._"-Ga6dge Grinder___'____,,_Lot Size..,.._'_L'--- ------- ---------- <br /> Water Supply: Public System and name-.-_ .... ,- <br /> _ f Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay D� ndY Loam s Clay Loam [❑ <br /> ' Hardpan ❑ Adobe ❑ i"Fill Ma—feMa-l' If yes, type--i i <br /> (Plot plan, showing size of lot, location of system in relation to'wel.Is, build ng's, etc.�must be'placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or se "age pit permitted if public sewer is.available within 200 feet,] <br /> SEPTIC TANK ['1 Size ': 11� w --- -- Liquid Qepth " <br /> PACKAGE TREATMENT "[ ) _ � <br /> -T e __"-Materialf�•_ ._'�`'C�c'�-_'�No.•Compartments----=--�`------� -- - r.,, <br /> Capacity_ _„_Type <br /> I� i <br /> Fundption_{---rta-i �- =Prop. Line.__ - <br /> ,. Distance.to nearest:-Wei l.:, --- <br /> to <br /> '__.___Len th of each line. . Q= <br /> s. ;_ Total;Length _..,,._._. `f� i <br /> LEACHING LINE... [ No. of Lines.-_.___3__ =:: .. ., g ”" <br /> ' - I <br /> a_ ..; :",- <br /> - <br /> D' Filter MateriallFilter MateriIr ept <br /> I O .Foundation_ - -- P�'operty Line ----------------------------- <br /> P - <br /> Distances to nearest: Well_ : - - d <br /> �. k Filled N <br /> SEEPAGE PI7 [ ] Depth----:----- Diame�terNumb+ s ❑ o ❑ <br /> Water Tdb[e,De'pth--------------- -------- �--~'` ---Rock Size_ <br /> } <br /> i . Disfance'to nearest: Welt—'=- - --------- Foundation _ '-.Prop. Line <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_'--------:-----------------=----- :Date_'__ = <br /> } =____ - ------- ------------ --- <br /> Septic Tank (Specify Requirements)---- :- --- _ - -----=--=---- --------- =----- - --- . -- - -. -- <br /> -----=------�-------- ---- ------` <br /> Disposal Field (Specify Requirements) y ---------------- ------------------------ <br /> . <br /> --� ---=-----= -- ------- ----- -- - ---- --------- --.--- ..---- --------- <br /> --------------------- <br /> ------------------------------------------------- -- - --- <br /> --- -------- <br /> - -------- ------ ------------ --------=---------------------------- -- d---------- :--- ------- <br /> -------------------------- -= <br /> { (D�aw existing and required addition on reverse si'Je) { <br /> 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: i <br /> "1 iertify that"in the performdnce of the work-for which' this permit is'issued, I shall not ernpioy any person in such manner as <br /> to become subject to Workman's C�.p, ation, laws of lifornia." <br /> r . <br /> Signed.-_. ------- - --- -- - - <br /> r <br /> : . <br /> -Title' <br /> Ji <br /> c (If other than owner) r s <br /> .. <br /> FOR DEPARTMENT USE ONLY <br /> } - ---------------- <br /> APPLICATION ACCEPTED BY- :----- ------- -----=------------------ = DATE.. <br /> ----- ------ - -- ---------------- =-------------=---DATE.:----------•- ------------- - :--- ----------- <br /> DIVISION OF LAND NUMBER-------------- ; <br /> ADDITIONAL COMMENTS------------------- - ----E----- ---- ------ ' <br /> ------------- ---------- <br /> ---------------------- -- <br /> r ------ ------------------ - <br /> --------------- ------------------------------ --------------=----- ----------- <br /> ---------- <br /> ---------------------------------------- <br /> Final Inspection b ----------------------------------- <br /> -= ---Date ------ --- � ? ------- <br /> --------------------------- <br /> Fos 21677 Rev. ���6 sM <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />