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r <br /> FOR OFFICE USE: <br /> 1�"� FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------- <br /> (Complete in Triplicate) Permit <br /> This Permit Expires 1 Year From Date Issued Date Issued/ <br /> -r�]-_--�� <br /> ,pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> nis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> OB ADDRESS/LOCATION---------------- --- ------- -----------.CENSUS TRACT <br /> )wner's Name....�.� 2Y1_ — ---_---- 6 <br /> _ CLG_v, ----------- ------------- --------------- ----------- Phone ,S_� � .y 7.y <br /> kddress..__ll 5--`�-- `�--- -----( AG�U -2..----- <br /> ..----..._ Zi _. <br /> C� <br /> tiontractor's Name.. jS.S----- "-- .--�14441U_1:5� --------- ------------ -License #------------ ------ <br /> - --- --Phone-------- -------- ----------- - <br /> nsta lotion will serve: Residence ❑ Apartment House.❑ Commercial ❑ 'Tr 'ler Court ❑ <br /> Motel ❑ Other- .o6zz.! <br />' Jumber of living units.-___./-------Number of bedrooms--,—__-Garbage Grinder-----------.Lot Size_ <br /> Mater <br /> _" " <br /> Mater Supply: Public System and name---_------------- __-_- <br /> ------------------------------------------------------------ ------------- <br /> Private � . <br /> - <br /> I --haracter of soil to a depth of 3 feet: Sand E) Silt E) Clay [D Peat EJ Sandy Loam ClayLoam <br /> f Hardpan ❑ Adobe ❑ Fill Material-------------If yes, type- <br /> ------------ <br /> Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side: <br /> +IEW INSTALLATION: (No septic tank or seepage pit ,permitted if public sewer is available within 200 feet,[ <br /> 'ACKA ' <br /> GE TREATMENT [ ) SEPTIC TANK [j,}/ Size.e -UC� --------------------Liquid Depth.J�--------------- <br /> ---No. <br /> ---No. Compartments__-__---- <br /> Distance to nearest: Well---------------------------------- --------Foundation----------------------....Prop. Line--- -- to <br /> ---------------------- <br /> _EACHING LINE [a-' No. of Lines.-------- Total Length : /irQ` <br /> -.��------ --.Length of each line.------7d"------. ---------- <br /> ------------------- <br /> 'D' Box-----/...T e Filter Material.`' fir"-�'�JD P '� J <br /> YP � ~- --- e th Filter Material.--�I�--- -----�-------- ------------- ------- -- ----- <br /> DistancE;to nearest: Well,-:''-r Foundation- >__10r _-_-_Property Line_,35?Sl'-_t <br /> SEEPAGE PIT [ ] Depth.........-------Diameter----------------...Number.------------------------------- Rock Filled Yes ❑ No F] <br /> Water Table Depth--------------------------------- -----------------------Rock Size--=-- -------------- <br /> Distance to nearest: Well.------------------------------------------Foundation--------------------------Prop. Line--------------------------, <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------•------------.Date--------------, ) <br /> Septic Tank (Specify Requirements)------------------ - <br /> Disposal Field (Specify Requirements)____________________ _ _ <br /> ----------------------- I <br /> --------------------------------------- -------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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 <br /> signature certifies the following: <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 /> to become subject to Workman's Compensa 'on laws of California." <br /> Signed._ <G --`----�-�- '04-e—... � �'�-oar. �1 <br /> -----------Owner <br /> BY--------- ----- ------Title----------------- <br /> ----------------------------- <br /> -- - - - -------------- - <br /> (If other than owner) <br /> R D PARTMENT USE ONLY <br /> 7 .....APPLICATION ACCEPTED BY------- -- ---------- -N----- � -------- -DATE.._..__._-.- --2 S ------ -- - <br /> / 7 <br /> DIVISION OF LAND NUMBER -------------- ----- -------DATE--------- <br /> ----------_------------ <br /> - E <br /> - ----------------- <br /> ADDITIONAL COMMENTS _.._..__ <br /> ------------------ <br /> ........ ----------------------------------------------------------- ---------- -------------------- - --- ------------------- ----- ------------- <br /> -------••---------------•--------------------------- ----- n n u <br /> --- ------- ' <br /> Final Inspection b �' i " n /� <br /> P y:...-- ... � j ------ ------------ ----- --------_--Date. �` ...._..- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6s 21677 REV. 7176 3M <br />