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APPLICATION FOR SANITATION PERMIT 7S 73i <br /> _.......... .. ._ . -...--....._..- <br /> (Complete In Triplicate) Permit No '--"' <br /> This Permit Expires 1 Year From Date Issued Date Issued J�.7.d <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> describecj�Thi opplication is made in compliance with County Ordinance No. 549 and existing Rules and Regulationst <br /> // .C',45T <br /> JOB ADDRESS/LOCATION _.... `f .YU-�--,_----- -y/V6TeE -- _CENSUS TRACT .......................... <br /> Owner's Name .....plewov......2ll-. -----• ....................- --••....................................Phone ...... .............._............ <br /> Address <br /> - - - ..........City -.'4Scg4ed -- -- <br /> Contractor's Name JQc1.-- - ----- --------------------------------- ----.License #-OA�--- Phone ......................._.. <br /> Installation will serve: Residence fig Apartment Houset] Commercial❑Trailer Court ❑ - <br /> Motel ❑Other----------------------------------------- <br /> Number of living units:-.Y------- Number of bedrooms,;�,.------Garbage Grinder _..--------- Lot Size ----- ......-.............................. <br /> Water Supply: Public System and name ..........,..........-f_. ......-....................._...................................-..........Privatek]r <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan I( Adobe 0 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 INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK( ] Size................................................ Liquid Depth _..-..... ................ <br /> Capacity ------------------- Type ------------ ----- Material...................... No. Compartments ........-..........--A <br /> Distance to nearest: Well ------------- ---...................Foundation --_------------------ Prop. Line ........-....._...... <br /> LEACHING LINE [ ] No. of Lines __.._ ............... Length of each line.._............................. Total Length ........... <br /> .-.......... <br /> .. 0 <br /> 'D' Box .....-.....- Type Filter Material ..........---------Depth Filter Material .............-.............................. <br /> Distance to nearest: Well ....---------------------- Foundation ........:..:............ Property tine ..--.---.---.-.-.-......f <br /> SEEPAGE PIT ( j Depth .................... Diametei .------....-. Number ............................ Rock Filled Yes ❑ No <br /> Water Table Depth ----`---------•--------------- --------------Rock Size ....................... <br /> - <br /> Distance to nearest: Well ....•---......... ------------------ -foundation .---------_-.....-- Prop. Line .......... <br /> . DfiREPAIR/ADDITIONlPrev. Sanitation Permit#/ ---.---•---•---------------------•------,- Date .................................. <br /> Septic Tank (Specify Requirements) -...-./.._-..l Ca�r--a r9 G T JYX.....-•................._---...--•--.....-- - .............. <br /> ( <br /> Field Fie <br /> Disposal (Specify Pacify Requirementsl,,,4-,EA-Sr-�-,/�,�s�G•'..--,raZ----XI..G-'t5.-.........srC1-- <br /> ---------­----- ------------------------•------------------------------------- -------------------------------------_-_--------•-------------------------------- ................:.---------- <br /> - --- - ----------------------------------- ._ '-- -----------------------_------------ ------. ------------- -...... ----------------........ ...........-....................------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ...... ._..-.............----.............• --------- Owner <br /> By ...---------- _----- Title _....... -- .._.......- <br /> - -- - - -- - - - - -- <br /> (if other Than owner) <br /> FJDR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... - - -- - DATE .. .3. �J <br /> BUILDING PERMIT ISSUED ... - - ------------------------------DATE --- ........................... .--- <br /> ADDITIONAL COMMENTS <br /> --- --- --------------- ------ -------------­-----­--- ............ .............. -- ----- ---... ..._..................... --....... - <br /> -- - ------- ---....... - - ----------- - - ------------------------ ------ -------------- - - - --. . ..............._.................... <br /> -------- ----- ------------ ------------ - - - - <br /> final Inspection by ----- ------------ - ........ Dat l....... - <br /> Date, .............. - <br /> El-1 13 2h 1-6 Rev. 51.t SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7 111 3M <br />