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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.-____--_ <br /> �, Date <br /> --------------------------------------------------------- This Permit Aires # ear From D to Issued i. <br /> Application is hereby made to the San Joaquin Local 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 /> _d- '�. d_� C_.sa- i <br /> JOB ADDRESS/LOCATIO _ q "Am_ ._ v_ �_ p?-_1_ Jrca_15. �_I ENSUS TRACT__ �'.� <br /> N. rr_Z <br /> Owner's Name._,Ed--.7 90*!o v-56q�!. 3---/1_+-e•- ---- ---- --------- -- -Phone_-I_•07h7=7 7_7%_ <br /> Address_. 4_a d._:.t10 ./ <br /> tic- ---- ------- -Cit --- --Zip <br /> t •..r. <br /> Contractor's Name_-- 7 -- --------- ------ --------------License # -- --Phone-..---- ---- - - <br /> Installation.will.serve: Residence [R�Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> Motel -❑ Other = ._.__=_:- = _ = ------- <br /> Number of living units:._y-------Number of bedrooms;,__--11---Garbage Grinder-_:_-___.,..,_Lot-Size--------------------------_---------____ _______________ ___ <br /> Water Supply: Public System and name. ---------- -------------=---------------------- ----------- r_---------=--- ------------------------- --------------------Private ❑ <br /> i <br /> Character of soil:to a depth of 3 feet: ' Sand ❑ .Silt❑ :Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam F 'I <br /> t Hardpan ❑ Adobe ❑ Fill Material_-__._..-._.If yes, type___________________ .._ l' <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,) r�r, <br /> r "S <br /> PACKAGE TREATMENT SEPTIC TANK ° <br /> [ l j.] Size- = -------- Liquid Depth.;------.- ZS <br /> Capacity--------------------`TYp? ---- ---- -----------Material_:: ........ ---,-,,-:No. Compartments----------------------------------- <br /> QS <br /> Nr- -T�: <br /> Distance-to-nearest:WeII F.ounda.ion ._:____.________P_rop..Line________________.______! <br /> LEACHING LINE [ ],-•-No._of Lines.....r -F--___-..Length_of_each-line Total Length --------------:--------------------° _ <br /> ' .--Type Filter <br /> Material :Depth filter Ma-te.rial Property <br /> Line- - __--Disante to nearest: Well- --------------------Foundation_ u__--.____. <br /> SEEPAGE --------------- ,} <br /> PIT __ r - t Rock Filled Yes ❑ Nor❑- <br /> Water Table De th = <br /> R --------- <br /> ] Depth____ _________ Diameter_._,__._.._ <br /> r <br /> • z <br /> um er--- ---- ---Rock Size-------°---------------------------------------- <br /> Distance-to nearest: Datedation-=-------------------------------- <br /> Septic <br /> -=- -.=----�-�-- -----.Prop. Line---------------=----- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------��__.___.:__ .______________________. _ _) <br /> Septic Tank (Spec ify. Requirements),__,_• = ---- -----------=-=--==---------------=-- -- - --=--=------ ------------------------------------- --------.- ----------- ---- <br /> Disposal Field (Specify Requirements( -.------=------`:------- _--------------------------------------------------- <br /> ---------- <br /> --------------------------------=---------------- r <br /> `F <br /> � t <br /> A it <br /> _________________________ ______________________________ ___v_ _ _ __.________.-_-________ ____.____.__________.______._______.._---.-__-__-__-____ <br /> Dra',wEexistir g and require addition on reverse side) I ; <br /> I hereby.certify that I have prepared this application and that.the work will-be done �n-accordance <br /> N cordance 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 certifythat fir► the - f '� '� <br /> performance of thewark for which,this?permit is Issued, I shbll not einploy any person in such manner as <br /> to b e j to Workman'i Compensation laws.of�€California:" <br /> Sig{ . . [I ------------ <br /> By-- <br /> -- <br /> �----=---- <br /> BY -- - ------------ �-----=-------------`--------- ----------------------- ----------- ------------ <br /> OTitle <br /> n-e-x-------- -e <br /> --------------- -------------------------------------f ° <br /> ' <br /> other than' <br /> g FOR.DEPARTMENT USE ONLYCy <br /> s I <br /> .. .fi �• , <br /> APPLICATION ACCEPTED BY-' - :: DATE _�Q.. ! Z 7---- ---- - <br /> DIVISION OF LAND NUMBER---------`_--- --.DATE------------------- ---- ------ -- <br /> ----------•- <br /> ADDITIONAL COMMENTS ----------------------------------- -=-------------------------- ------------------------------ ---------------------- -------:------ ; <br /> ! + <br /> - -----------------------------------------------:-------------------- -- e_-------------------------------- <br /> -- ------------------------------------------------- <br /> ------- --- ------------------------ --.---------------- ------------------------ ----- ------------ — e <br /> Final•inspection by:_ =" = = :: - --Date C/'� F <br /> EH 13 24 5 N JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/7613 <br />