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-FOR OFFICE USE: -- � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION(®R <br /> Komplete in Triplicate) Permit <br /> I <br /> _______________________________________.... ............ This Permit Expires 1 Year From Date Issued Date Issued_2.:/..rP _7�19 <br /> Application is hereby made to the San Joaquin Local Health Di.fr`ict for a permit to construct and install the work herein described.This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOS ADDRESS/LOCATI N_.. �--g Nr'.= '�"` CENSUS TRACT ._.._.................. <br /> Owner's Name -- ¢ --------------------------------- .--.----.Phone------------------------------ <br /> Address-------------r ----------------------------------- ---- ..........City ------- Zip--- <br /> a � <br /> Contractor's Name------_----- _ �ac�__ .. -__ �'l.icense #__- ZZ... hone--•-••-------------•-- --- <br /> Installation-will'serve: Residence ❑ Apartment House Commercial ElTrailer Court E]:. ._.. Motel E] Other.....1 --------- ------- <br /> Number of living units__---------------Number-of bedrooms........,___Gar---Garbage Grinder Size-----------------------.._.__.________..____ �.._ <br /> Water Supply: Public System and name �: :: ------ ------ -------•---•--- __......Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Slit❑ Clay❑ Peat❑ Sandy Loam [Clay Loam D k <br /> Hardpan ❑ Adabe o Fill Material..........-.-If yes,type-------------------------------- <br /> (Plot <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:" lN6tse'ptic tank or seepogi§ pit permitted if public sewer is available within 200 feet,)_JZ 'al <br /> PACKAGE TREATMENT' Size -` Liquid Depth. - ------------------ <br /> [_] -SEPTICTANK [�' ; L '� x �a �'' � <br /> r Ppadty_.- 9-Z 42 YP ---- . CompartmentsV <br /> �-...Ca dci 7 T e_ ____ Materiai__.___.� ----- ,No. _._______.17.......:..........$�� <br /> Distance tonea^rest Well.............7WW�-----------------Foundation-----------fid-----_-Prop. Line---- ------------------- <br /> LEACHING <br /> ------------ --LEACHING LINE /No. of Lines---------_�__".____ <br /> T" ..-:;---,:-..Length of each line..-.-f-QQ----,----_':--::..Total Length._... -----_;-:_`� <br /> 'D' Box__:_/....Type Filter Material,-J-9-1411 'al..Filter Material..____ ------------------------------------ <br /> Well <br /> _: __ .__ <br /> ---------- -------- <br /> Distance to nearest:WeIL_____elf.. _.._..Foundation...•__., __.___Property Lme....o5-------:......:..... .... r <br /> SEEPAGE PIT j ] Depth---------- ----Diameter--------------- ----Number..........-----------------,___-. Rock Filled Yes ® No❑ <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)-----•--=--------------- =...................... --------.._.--------- ----------- ----------------------------------------------------------------- -••-- -Disposal Field(Specify Requirements):....Q - Ltt-s-G - .... _ u-------------------..................... <br /> -----------•---------------- ----------:.--.------ ------------ �Q ------------- -------- <br /> _____ ___------_---------------------______----------- _________________________________________ ____y_____;'-_____--__.__._..-..--..-.-.I--.•-.-.___-.__________.__-______._-____.R--- <br /> (Draw existing and required addition ori 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 age;ts'--- <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 'subject to. Workman's Compensation.laws of California." <br /> Signed--------- - ---- -------------..:_---=--------- - --- - -----Owner �- c <br /> BY = ------------------------------- <br /> By-- <br /> ... = Title. .... ------ -------------------------------- <br /> '(If other than owner)' <br /> FO k DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.___. __r____ ._. ._-------- <br /> DIVISION OF LAND NUMBER.-__. - • - -----------:----------- -------------------------------------DATE-------------------------------------------- <br /> ADDITIONAL <br /> ----' - r <br /> ADDITIONALCOMMENTS----------------------------------------------------------------------------------------------- ------------- ----------------------------------------------------------- <br /> - ---------•----------------- --------- -------------------•-•------------------. -•-=-------------- -----•---------------- ----------------------------------------------------------------------------------- <br /> ----------------------------------------------------- <br /> ---------------------=--------- .------- ----------- <br /> --•---------------------•---- -------------------------------------------..._..._....._....... -- - --------------------- <br /> Final Inspection b '� - - Date--_ 3�. ----- <br /> ....... <br /> ........... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 5 21677 REV,7176 3M <br />