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Y FOR OFFICE USE: FOR OFFICE USE: <br /> t APPLICATION FOR SANITATION PERMIT <br /> i ----------------------------- ---------------------- -- - X77- '3 S3 <br /> (Complete in Triplicate) Permit No•__._._____"--_______ <br />- ------------------------ -------------------------- ----- S.1/ <br /> ____ <br /> • --------------------------------------------_-__._------ This Permit Expires 1 Year From Date Issued Date Issued_-_ ______7 <br /> Application is hereby made to the.San Joaquin Local Health District for a permit a'c ns uct and install the work herein described. }. <br /> This application is made in compliance with County Ordinance No. 549 and existing kules�and Regulations: <br /> JOB-ADDRESS/LO <br /> L_{f1/ ------ <br /> P _O /C� _.__ - r - - ------CENSUS TRACT,/6'0./,01_1-------- - <br /> f <br /> Owner's Name 07 <br /> Owner's ""1 p��1¢.. ----- -.-.-:------- -- ---Phone---� j�/��j 9� <br /> i 04 . . _) 3 --- --------- <br /> Address - �C�Q/ _..-"L�t� `. -----CVo!7' ' -- ----- City . __ ----- ZiP <br /> ---------------------------- <br /> Contractor's Name._ _ _"_______-------License #-t� �lPhone: r_ <br /> Installation will serve: f Residence ❑ Apartment Hous o mercial ❑ Trailer Court,❑ A <br /> t w f Motel ❑ Other_=I'1C - ---units: Number <br /> _ <br />'f Water Supply: Public System and name------------------ --- ----- <br /> ------------------------=-------------------- <br /> ------------':--Private <br /> Character of soil to a depth of 3 feet: Sand [] 'Silt E] Clay F] Peat ❑ Sandy Loam Olay Loam ❑ <br /> _.. <br /> .. <br /> f � Hardpan ❑ ' :Adobe ❑ Fill Material_.;. _-__If yes, type."__' <br /> --------------------- <br /> (Plot plan, showing size of lot, location oiksyster-.Jn­relation_to 1welIs, buildings, etc. must be-placed on reverse side.) i <br /> NEW INSTALLATION: '(No'.septic tank or seepage pitpermitted if-.,p_ ublic sewer is ava1Iablee_y;ithin 200 feet,} <br /> PACKAGE TREATMENT J <br /> I ] FSEPTIC TANK j ] ��-* ' .. Size r Liquid Depth <br /> = - <br /> ----------- - - -- <br /> ' >t. I <br /> f Capacity---------------------TYPe------------ ---- -----Material- ' ------?_-=-- No. Gomportments__�----- ------`------------ -- <br /> - Distance to nearest: Well,_--____.----------- _ � <br /> r s - _ =--- Foundation---------------------------Prop• Line__----'-=------=----- <br /> LEACHING LINE ' <br /> No. of Li_nes '_ ------------ - --.-' ---- engt `ofeach line------------ `-------------===-Total Length------__-------------------------- ----- <br /> 'D' Box..........__Type Filter Material"'-__- <br /> ' <br /> _ ----'�---'-`--'----Fou Depth Filter Ma�rial--------------'----- - - - --------=---'------- ---------- <br /> --------- - -- <br /> Distance to nearest: Well_:____-__1_ dation.__'__-_..___."_______.__..Property Line___- _________.__._ <br /> SEEPAGE PIT � P� � �.� -' _ - - ---- ---- <br /> ___" �. Rock Filled 'Yes ❑ No <br /> ] Water Table Depthmeter" "_,_-Number Rock N,••• <br /> l �. <br /> ( Size - ;---- -------- <br /> Distance to nearest: Well.____.". 1 �9__-___f Foundation .__-___. F--------------Prop. Line--------------_ _____ <br /> "f 1 <br /> .>ti <br /> REPAIR/ADDITION (Prev. Sanitation Permat�#-=-- _-- ----'--:-----------------Date------------- :--'-- "------ -_--- l <br /> . - . <br /> Septic Tank (Specify Requirerrlents)------•:_.:________ . , ] <br /> Disposal Field_.(Specify Requirements)_____! """------- <br /> Y_ ----------------------------------------- <br /> _ f <br /> --------------------------------- <br /> --------------------------- <br /> ________________________________________----- ------------------------ ------------------- ' <br /> ------------ <br /> (Drew existing and required addition.on reverse side) <br /> hereby certify that I have-prepared this application-and that the work will be done 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 i <br /> signature certifies the following: , <br /> "I certify thavin the performance of'the 'Work for--which this permit is issued,-.[ shall not employ any person in such manner as <br /> to become subject Workm s Compensation;laws of California." y .. <br /> Signed----- ----- --- --------- " -- - ---- ------- - ---- ----------- Owner <br /> ' r <br /> By-� -'--- ------ :-� --- : -- - ----- <br /> - ----- --- ------ --- ..-..Title -- <br /> (I other than owner} i <br /> # FOR DEPARTMENT USE ONLY # <br /> APPLICATION ACCEPTED BY------------ -------' ----- --- - - -----DATE._- �1� ' <br /> ---------------------------------- <br /> DIVISION OF LAND NUMBER----------------]- ----------- ------.DATE <br /> ADDITIONAL COMMENTS----------_---- _""-_I-._.__ <br /> - ' ----------- <br /> ------------------------'------------- --------------- --- <br /> ---------------------=---------- ------- } i <br /> .� -- ------------------ - ---------- -------'------------ <br /> - <br /> Final Inspection b • - ---- !�,_" --------------------------------------------------- <br /> _Y_ --- ------ ------ ----- �� <br /> y - ..� <br /> --- -- - --- - -----.Date"' <br /> eH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7176 3M <br />