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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------ - --- -- ------ <br /> (Complete in Triplicate) Permit No.- --._-. <br /> -- <br /> --------------------------------------- ----------------- <br /> Date lssued.l�..�.�5.: <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> I <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 /> .. t <br /> JOB ADDRESS/LOCATION .... . -----•-- .,3CENSUS TRACT------------------ ------- -' r 7 ' <br /> Owner's Name -_. IT, <br /> Address..- .-rf.._.Jst![ % =`� ...............City rW <br /> tZ C <br /> I _.r� ` <br /> Coniractor'dName--- � �. ------ --------License #.. '_6 Z Phone.. .�+?. �.... <br /> I Installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other........-_- (� <br /> Number of living units:....I.......'' __Number of bedrooms.__. Garbage Grinder------------Lot Size---------- + ........ ..................... <br /> . � <br /> Water Supply: Public System and name -- - - --------r --- --------- ------Private 19 <br /> Character of.7soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> 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 INSTAL;ATION: (No septic tank or seepage pitpermitted'if,public sewer is available within 200 feet,) , <br /> PACKAGE TREATMENT [ ] SEPTIC TANK j ] <br /> _ ..S..iz._e..�. 0�.*��_� 7�....------- - •-------- -Liquid Dep. th . ��:t <br /> . -.....-.---- <br /> - <br /> Ca acit /�� T e e�CASMaterial_........__._....: . No. Compartments... _._ <br /> Distance o nearest: Welll_,_..Z- ,0.._7------ ---------Foundation..,/A. .... <br /> -� <br /> � ..Prop. Line_..,�lkJ -.......C1, <br /> LEACHING LIN.E--[--l—No •of-L-i-nes :_w --..-- -lengthmof-each gine._:_- Q.-. •----Toxal_ length.:... !d3--- ----' <br /> D' Box...t.......Type Filter Material.) odk.! Depth Filter.Material...--.�- - ------------------------ ---- --------------- <br /> Distance,to nearest: Well-_`l° -----�....Foundation_.J�o-.�.�--.-Property Line..,/.. ��------'� <br /> I. SEEPAGE PIT [ ] Depth.'- - __-Diameter--------------......Number----------------.._------------- Rock Filled Yes ❑ -1 No <br /> t <br /> i Water Table Depth- :-----•------- ---- --- --------- Rack Size... r <br /> Tpistonce to nearest: Well. -.-------_ ------Foundation--------------- --------Prop. Line.......------- ' <br /> REPAIR/ADDITION {-Prey:-Sonitation-Perrntt#_�-+ .......:................. ........... .-.Date....---- --- 1 <br /> Septic Tank {Specify Re-qairements). i,. : _# -- - ------------------------------------------ - ------------•------------ .............. <br /> ------ <br /> Disposal Field [S ecif Reau ecents] - <br /> ------ ------- -------- ---------------- - - ---- <br /> ----------- -------------- <br /> ---------- <br /> ------------------ <br /> ------ <br /> ----- .--•---- .-- - - - iiii <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that-the <br /> work will be d6ne 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 tkisjpermit is issued, l shall not employ any person in such' manner as <br /> to become 'Subject to for a W s G pensution laws of California. <br /> Signed---.... ;. % f.+.+ '!�C/... :.. `. .._ ner <br /> By....----------- ... - -----......kTitle-------------- ------------------- -------- -------------------------- _ . <br /> (If other than owner) <br /> FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- ---------------- ---------- -------DAT - .... <br /> t <br /> DIVISION dF LAND NUMBER......-- -=Y ---= - :-:. -- -..--DATE._.............._....., ..�:. ,... <br /> ADDITIONALCOMMENTS.....--------------.... ... . � ------ --...... -------------- ........... ----------­------- -------- <br /> ----------- <br /> -- ---- <br /> ---------------------------------- ---------------------------- <br /> ............... <br /> --• -•-- .......... ------------------------------------------------.__._----- <br /> „ r- <br /> Final Inspection by: . ....---- -------------------------------- -------- ---Date._ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EH 13 24 - f&s 21677 REV. 7176 3M <br /> C� <br />