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--�- <br />MPNPPP- <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> \ (Complete in Triplicate) Permit No._____ <br /> ------------------------- ------------------------ ---- <br /> Date Issued__/,,�= 7,7 <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 compli ce with County Ordinance No,549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI N.------`fe, �=--� -` - �, �''K_ . - -�- U T T <br /> Owner's Name.--- - / <br /> --"'S'---lel--- ---- -- = - ----------------------- <br /> . --------------------- - _ one------- ------------------------------ <br /> Address------------J7 <br /> ----- ---------------Address-----------J`I ----- - -, - ._�Cl ---------------------------------------Zip_`--- <br /> ------ ----------- <br /> Contractor's Nam -__. __ .-, �L�,�,a,��!___�1,_License #- _ _ Phone �� <br /> Installation will serve: Residence[ Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> / Motel ❑ Other--------------------------------------------- <br /> Number of living units:.--__-`__'__Number of drooms___. --_Garbage Gri _°_ __�t ._tot Size---1L.l_ __Gc____ _____...__-_______-- <br /> Water Supply: Public System and name - � ! - Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay F-1Peat E] Sandy Loam E] Clay Loam F-1E]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 ifpublicseer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size__ __---_X k - _ <br /> -------------Liquid Depth--- ---------------6J <br /> Capacity/_2"-li��ype_ _ _ _ aterial___ _ _ o. Comp,artments_.-__' -_______________________r <br /> Distance to nearest: Well------- _____________________Foundation___167------------- _ <br /> ______-_Prop. Line__ _--.�.________- <br /> LEACHING LINE No. of Lines_________--___-__Length of each line._ __L, _______________.Tottaal Length -_ __________._______ <br /> D' Box-.._____Type Filter Material -.Depth Filter Material___F-__ ._f�_____._______________________._____-_---v <br /> Distance.to nearest: Nell_4�`__ _ _-_______Foundation-__ _ Property Line -�`------ ___----- <br /> r <br /> SEEPAGE PIT [ ] Depth---.------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑O <br /> WaterTable Depth---------------------------------------------------------Rock Size.---------------------------------------------- <br /> Distance to nearest: Well--------------------------------------------Foundation.-------------------------Prop. Line--------------------------- C <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date___________________.____________._-________) G <br /> SepticTank (Specify Requirements)----------- -------------------------------------------------------------- ------------------------------------------------------------------ ------ <br /> DisposalField(Specify Requirements)_-------------------- ---------------------------------------------------------------- ---------------------------------------------------- --------- <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 to Workman's Compensation laws of California." <br /> Signed - - Own�er <br /> --- - - - -- ---- CL.ARENCE'S SEPTIC & SEWER SERVICI <br /> BY--------- ---- ta- t - . ----- ------- 7 3 Se: Sloe#�Ier9.,G itt, 952fl. <br /> (If other than owner) ;- , r :stfic. Lfi3z7/i� <br /> FOR DEPARTMENT USE ONLY ;t <br /> APPLICATION ACCEPTED BY------ - -----------------------------------------------DATE.-- % ------- <br /> -- - --- ----------------- <br /> DIVISION OF LAND NUMBER.------------ --------------------- ---------------------------------DATE------------------ - <br /> ------------------------------ <br /> ADDITIONAL COMMENTS----------------- / <br /> ADDITIONAL - <br /> ------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------- -------------------------------- <br /> --------------------------------------- - <br /> -------------- ----------- - ------ - <br /> Final Inspection by: Date 7i <br /> --------------------- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 RE�m <br />