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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT }, <br /> Permit <br /> ------------------------------------------------------- - <br /> (Complete in Triplicate) <br /> ------------------ Date Issued4-`-1--- -- T <br /> ----------------- This Permit Expires 1 Year From Date Issued <br /> ----------------- <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 /> JOB ADDRESS/L CATIO a!_- -:_ _ `•: f � 97 -- CENSUS TRACT ---------r-- <br /> --------------------- <br /> Owner's Nam r -�-k T('e------ - -------- ---- - ------- - <br /> ` <br /> - ------------------------------------ ----------Phone__ <br /> i 5 �j <br /> Address �y, ilQfti__ N2.0 it` y Zip <br /> 7 <br /> C - Z i _ �- <br /> Contractor's Nam, --- ------------------------ ------ ------ - ------------ License # _ Phone <br /> Installation will serve: Residence ❑ Apartment Wa Commercial ❑ Trailer Court ❑ <br /> + :pt Motel ❑ Otherl'? � 'C i <br /> Number of living units:_. `` �' "" <br /> - 1____Number af.bedrooms__ ._-_Garbage GrindE`r�J� --_Lot Size--,5 .........._.z __ <br /> Water Supply: Public System:and name-----------"----- ----------------------- ------Private <br /> Character of soil to a depth of 3 feet: S nd,❑ S' t ElClay E] Peat E] Sandy Loam [_1Clay Loam E] S <br /> :Hardpan ❑ Adobe � FLI Material.- --_.._-__If yes, type----------=----------------- -- <br /> , . <br /> i <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,) <br /> r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] r-Siz�`r _. --- ---- Liquid Qepth______________________ ____ <br /> T <br /> ` Caacit �aC Tjz[r� Naterial ---------------No. Compartments '----------------------- <br /> p Y-- YP _ r <br /> Distance-to ynearest: Well_-----,.,._-.------ ---Fou ndation------------- <br /> -------Prop. Line-------- ---------- --- <br /> LEACHING LINE [ ] , No.`of Lines.__ !a.__.Lengt 4f each linar_,_;,, a_".p- --.Total Len _______ _________ <br /> --------------;� E <br /> 'D' Box--.r ------Type Filter 1Nateri� __----r -De th Filter Material --:--1 -------------------- ---------------------- <br /> n <br /> -------------- ---- <br /> } Foundation s--------------- --P or perty Line----d ------------------------ J.. <br /> -_. <br /> p r �. <br /> SEEPAGE PIT [ ] De th---------- - --Diameter-,.----_- --`Number__-,_5________--------- Rock Filled Yes ❑ No <br /> Distance.to nearest: Well__-_--:- <br /> Water Tablp`Depth_ t-ivi _>_ r:r - - --=--- --Rock Size----------------------------------- -- t <br /> ti ----------------------- <br /> -------------- <br /> DatWell ---- F ° Foundation- .Prop• <br /> LineREPAIR/ADDITION {PreySanitation Perrmit# - ---=-- ----=- -� ---- ' Date----------------------------------------------) <br /> Septic Tank (Specify Requirements)----- <br /> €� -- -------- - --------------- ----------------- ---------- <br />{ i' <br /> Disposal Field (Specify Requirements);---- ------=- ------ ------------------------------------- ------------------------------------------------------------ ---------- --------- <br /> -- --=------------------- ---------------------- -------------- ----------- ------ - - ---------------------------- -- <br /> f - ------ - -------- ------ <br /> ----- ---.-------------- ------------ ---------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this-applic ticn_and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulaors:tiof5+the San Joaquin rLocal..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, 1 shall not employ any person in such manner as <br /> to become--d kman' compensation'. laws of California."�. <br /> Signe -- -- -- ---- --- --- I :.. Owner <br /> BY ----------------------- --------=-------------------------------:-------- <br /> ------------- -- -------------------------------- ---- ------------ 1t <br /> [ T' e <br /> (If other than owner) ' <br /> F FOR DEP MENT USE ONLY' <br /> K <br /> i <br /> = <br /> APPLICATION ACCEPTED BY- -- --------- . L <br /> DIVIS16N OF LAND NUMBER------------ --------------- t------'-- ---------- DATE <br /> ADDITIONALCOMMENTS-- -------------------- ----------------------------- -------------------------------------------------------- ------------- <br /> 1 <br /> _ ___________________ <br /> _______________________________________________ _______-_______ <br /> kI ------------------------------------------- -------------- ---------•---------- --- --- ------ <br /> ---------------------------------------------------------------------- <br /> -by------- <br /> = --------------------- <br /> - - ------------- <br /> Final Inspection'b ^' Date-- -- <br /> Y <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&5 21677 REV.7176 3M <br /> i .•_ <br />