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FOR OFFICE USE: ,FOR OFFICE USE: <br /> v (Com lete in Tri licate] <br /> APPLICATION FOR SANITATION PERMIT _, <br /> --------------------------------------------------------- P Permit No,7?'_I P <br /> --------------------------------------------------------- <br /> Date Issued.,T_1-�'�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. 544 and existing Rules and Regulations: <br /> t_ - 4 1p��P.------ -- ----- - <br /> JOB ADDRESS/LOCATION.---,-_-_.f-�_ --__-.�- _ P� _.__-_.-{----------CENSUS TRACT_--------.--_-------___--. <br /> fOwner's Name -- --- --- ----- ------ ---- --------- -------------- -------------- ----------------------------Phone --------------- <br /> Address --- ---- - ---- --- ----------------- ---- ------------ D------------------ --------- --- ----- Zip- <br /> --Contractor's Name AsG,�_ V-4 --------------------------------------------------License #_4V5_S.2--------Phone �� `�'1 5 / <br /> Installation will serve: Residence( Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> € Motel ❑ Other------ -----------=---------------- --------- <br /> Number <br /> --- <br /> Number of living ui nits:----?----------Number of bedrooms.-.--T.__-Garbage Grinder------------Lot Size---------- --------------------------------------- <br /> Water Su.PPIy: Public System and name-----------------------------------------------------------------------------------------------------------------------------------Private <br /> Character of soil toss depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ ; Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ____If yes, type-------------------------------- `- <br /> �R1 <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: (No4'septic't6nk or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-- Y 15--- ------------ -- --Liquid <br /> I --- . D.istance-to_nea re.s.tw•Wel <br /> D <br /> epth.--6�-'.�- <br /> -�-_-._`- <br /> Ca acit ._-- ---Type/?46s47 --------------------- Com artments --------------------------- <br /> r— <br /> ------------ - <br /> r � -� Prop <br /> , <br /> LEACHING_LINE:. [:] No. of Lines__ g g � <br /> ._______ ....__.__.Len Length of each line.____. _ � Total Length _ __l!;f5�O__�'_________..__ <br /> D' Box...I'-----Type Filter Material-% •'_VDe th Filter.N4aterial____r� __/__ <br /> Distance to nearest: Well_/Lr"iY. .___._____.Fou <br /> ndation_ ----__-_ <br /> Property Line 1----- --- <br /> SEEPAG�E�P1 [-]`-�—Depth -- r--Dicrtn'eter __ --Number__'--- ---- - -- Racl-FiiI6d! Yes❑`"" Trio❑ <br /> Water Table Depth-- w -------------------------------------------Rock Size------------- ---------------------------------- <br /> Distciii'ce to-nearest^'Well -" -___7 r ----- --- -- Foundation--------------------------Prop. <br /> * Line--------------------------- <br /> REPAIR/ <br /> ---------------------- --- <br /> REPAIR/,ADDITION {Prey. Sanitation Peit#------- -'r ----------_ -[--'--- <br /> --------Date---------------------: ---------------------.- <br /> --=--------------------------------- =---------)- <br /> --------------- ------ ---------Se tic Tank (Specify Requirements)-_.-_ ._ -__--._V <br /> Disposal Field (Specify Requirements)_-_-------- ---- - ----- ---- -- -- �"� �` -------------- -------------------------------------------- --------- <br /> } -* -------- ------------------ -------------------------------- <br /> ------------- <br /> ---------- ---------------- <br /> _..:� � <br /> (Draw existing and required addition on reverse <br /> I herebycertify that 1 have•prepared.this application hat-f}�e-work�H-b'e-dnn"nom ceordance with;San Joaq[in County <br /> Ordinances, State Laws, and Rules and Regulations of 'the" San Joaquin Local Heal#h Distriic�Hon a oviiher or licensed agents <br /> j <br /> signature certifies the following: <br /> p y° <br /> "I certify that in the erforrrtance of the work forywhich^this pe�niifi"is issuet�;1`"sliall"r�ot employ any person in such manner as <br /> to become subjecto orkma 's Compensation 'laws of California." . . <br /> Signed---� �"' --�'-- -_ - --------------------- -- ----�------------ -------- ----Owner. - <br /> BY=;--------t--------------- ---- ---=------------- -------------------------- ----------- --------------Title ------ -------------------------------------------- -------------------- <br /> (If other than owner[ <br /> OR D PARTM NT USE ONLY t <br /> ADPL•ICA ION-AC-CEPTED-BY=..r Z- �1----.--_:. ------------ <br /> DIVISION OF LAND NUMBER------------------ ---- DATE------------------------------------- <br /> . f <br /> ADDITIONAL-COMMEN.TS-.__ _---__..__-­.___-.- - - <br /> -------------------------------------- '---------------------------=----------------------------------------------------------------------- ---------------------------------------------------------------------- <br /> ------------------------------- --------- - ---- ----- <br /> ------------- ----------------------------------------------- - ---------------------------------------- --------- <br /> Final <br /> ----- ----------------- <br /> Final y.Inspection b --_---- - ----------------------------------------------------- _Date p - <br /> P <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M <br /> - <br />