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FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> -, .✓`, �' �acPPLICATlON FOR SANITATION PERMIT <br /> Permit <br /> ------------------- -----------d------------------ <br /> (Complete in Triplicate) i <br /> ---------------------------------- <br /> ---------------------- Date lssued.5.-�* <br /> This Permit Expires 1 Year From Date Issued <br /> a <br /> Application is hereby made to the San Joaquin Local Health District for a per h to`construct,and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rulesan�d Regulations: <br /> CENSUS TRACT.----- -------------------------- <br /> JOB ADDRESS/LOCATION_ <br /> -:ZO- ; 47 <br /> Ph 3 <br /> --- one'T� <br /> _-"----._r_-.-__-- --_._-._.--------------- _. <br /> Owner'sName---------- -- -- -- '- - - <br /> Address------------ ------ -- ..- f ------------ Ci <br /> tY Zi <br /> P 6"07 <br /> - ---� ----�� ----- --- License # - �:_1..'��-------P ones-Y'.�!. <br /> Contractor's Name------------------ <br /> -l__----- ---- ---- - <br /> lnsfiallation will.'serve: _ Residence`s Apartment Nouse ❑ Commercial ❑ Trailer Court ❑ _ <br /> Motel ❑ Other -------- ----- ---- --- ----- <br /> r <br /> ,�. <br /> Number of living units: -.--_Number of bedrooms a Grihcler-- .-- AotSize--------------------/ ..- --- <br /> private ❑ k <br /> Water Supply: Public System and name------ ------ ------- ------- <br /> Character of soil to a depth of 3 feet: ; Sand ❑ Silt❑. Clay ❑ Peat Sandy Loam ElClay Loam ❑ <br /> i Hardpan❑ j Adobe j�j,' Fill Material-.------- -If yes, type----------------------------- <br /> {Plot plan, showing size of lot, location of s sfiem in relation o well s,-build-ings,'etc. must be':placed-on-reverse side.) f <br /> Y Y.. s �- <br /> ' ink or seepage pit permitted 1f public sewer is available within 200 feet,) M <br /> PACKAGE TREATMENT- �j -]° .- t "1 <br /> NEW INSTALLATION:` ...(N'o. SEPTIC Size = - ------ - —Liquid Depth--------------------------- <br /> TANK ['l ` - -- <br /> T e------------ --_Material =. } <br /> Ca acit _ oundatNo. Com artments----------------------------------- <br /> { Distance.to nearest: Well-----=--=---- ------ ------, i ion. = ' Prop. Line Y <br /> Length of each line." _- € Total Len <br /> -gth.r --_------------------------------- <br /> I i_ <br /> LEACHING LINE f,] No. of Lines---------------------- -- 9 . :' ! <br /> I ! <br /> j D' Sox ......#' Type Filter Material-------=- ----------Depth Frlter M'aterial--------- <br /> . ,_- e <br /> + pro er Liine--------- --- - - - <br /> Distance to nearest: Well--------------------------.-Foundation. :- :-" � tY -� <br /> .. RFilled Y <br /> . is <br /> SEEPAGE PIT [ j Depth----------------Diameter. ------Number- I-------------- ----- ock es ❑ No Gds <br /> Water Table Depth---=------------------------------------------------ --- Roc ze-------; ---------- --- --- <br /> k 5i -------------- <br /> --- <br /> -------'Foundation,-°- -- -- -- i Pro Line------ -----•--- ----- <br /> Distance.to nearest: Well-------- ---------------------- P' <br /> (Prev.:Sanitation Permit#--=-- -- - Date-_ -_--'- ------ <br /> REPAIR/ADDITION -- -"- <br /> --------------------------- <br /> ---- <br /> - ------ ------- ----- <br /> Septic Tank (Specify Requirements) ' <br /> - I----------------------------------------- <br /> -f Disposal Field,(Specify Requirtemer.>ts)------- 4� M. :----------- . ) <br /> -------------------------------------- <br /> ----------- ----------'--------------------- . -------- --------- € <br /> i <br /> I -------------- -- <br /> -- --------- --� <br /> _ -�-" - -- <br /> F (Draw existing and required additiomon reverse side) �1� <br /> I hereby certify that I have p4ared this application pn&that.the work will be done intaftordance with San Joaquin County <br /> Ordinances,' State Laws, and . Rules an�Regulatsonsa of.:the' San Joaq,�sm Local Health District. Home owner or licensed agents - <br /> signature certifies the following: E I <br /> l <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 /> fto become subject to Workman's. Compensation laws of California." <br /> Signed-:------ ---- = <br /> --- -- .: --. Owner <br /> ------ ------------------ -- <br /> By_ <br /> If other than owner) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- ----------=------- ------------------- <br /> DATE <br /> -"r �"-7_ ---- --------s--- <br /> DIVISION OF LAND NUMBS -- --------------------- <br /> ------- <br /> DATE..'------------------------------- == <br /> ADDITIONAL COMMENTS---------- -J----------------- <br /> ------------- `- -----------I� ------- _A_ - = --- <br /> ----------- <br /> d. �r ---- --- --- --- ----- ------------- -------------------------------- <br /> ---------------- <br /> ---------------------------- -. <br /> r -___ .�:i-___---___-.-- -s _______________ <br /> 1 ; - ------- --------------------------------------------------------------------- <br /> ------------ --------------------------------------------- ---- <br /> --------- <br /> v ` <br /> -------------- <br /> ----Date. ---- ---------------- <br /> Final <br /> --------------- <br /> Final•Inspection by:- - ---==--- --- <br /> -- ' "' r65 2167 I 63n <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />