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FOR OFFICE USE: <br /> . APPLICATION FOR SANITATION PERMIT <br /> ............................................. .. •••• permit No. 7-:-: <br /> .................................................. <br /> (Compleb In Triplicate) �.., . . .. .. _ _ _.- : .. <br /> 5 <br /> ? <br /> d �-c .K...Z7 <br /> .........:........................................ This PetmU ar Expires 1 YeFrom Dale Issued Date issue • <br /> Application Is hdreby made to the San Joaquin local Health District for a permit to construct and install the work herein <br /> described.This application Is made in compliance with County Ordinance No. 549 and existing Rules and Regulations <br /> 6217 <br /> JOB ADDRESS/LOCATION ..ssft?'rltS2�._O1aacJ. 1t.��..�r�y...UMk-S0u1<.L...west........CENSUS TRACT ......................_». <br /> Owner's Name .......................•--..........._.........................c:..,.................._.Phone ..%Lflga-a 8 .... <br /> Address ... q. ......45.,,_..n�..7�4-r{.�R .............•--.....-•---.,_.._..-............_...City ?✓.0c�t4.........----------..,.__-_---------_-.......... . <br /> Contractor's Name.... - ................License# .......... ..........-... Phone .-..-.... --_--_.--•----- . <br /> installation will serve: Residence 0 Apartment House❑ Commercial]_}TrailerAepOr o <br /> Motel Q Other......-'-----•--..._•..................... <br /> Number of living units:..... -.... Number of bedrooms ....!.....Garbage Grinder ...........: Lot Sin ................_... <br /> Wow WaSupply: Public System and name ....--._:_............... ..._--------------------_--------_--_::.-..-----•-------_-_.._-----Privme'a <br /> Character of soil to a depth of 3 feet: Sand[ Silt Clay 0 Peat❑ Sandy Loom ❑ Clay Loam f� <br /> Hardpan❑ Adobe C] 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 f ] SEPTICTANKPI Size. .t..5`.3. S`.................... Liquid De <br /> Capacity .lir-Oa...._ TYpe la MaFerial..Grfcr' -:..... No. Compartments ...A ....____. <br /> i <br /> Distance to nearest: Will ....;..d.Q:....................Foundation Z�.._....-.......Prop. Line-.2... .. <br /> ._. ........5 <br /> LEACHING LINE No. of Lines ...)...•............... Length of each Iine..rt..p9.............. Total Length ?!................... <br /> • 'D' Box ..--.-.--*L Type Filter Material ....................Depth Filter Material ............................................ <br /> u, c <br /> Distance to rarest; Well ......................... Foundation ........................ Property floe ......................:� <br /> SEEPAGE PIT ( ] Depth ........ ....... Diameter ................ Number ........._................ Rock Filled Yes Q No [3 <br /> Water .Table Depth ................................................Rock size . <br /> Distance to nearest, Well ------:..................................Foundation ...........:........ Prop. Una ........._....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ..........................._................ Data ........................... <br /> Septic Tank (Specify Requirements) <br /> ...: ......... ............................:.........................:_..........................._....... <br /> _............... <br /> Disposal Field ISpecify Requirements) .................................................................................................................................... <br /> .. <br /> ._.............................................. . . ........................._........---•--..._.......:.....-,_-....._..---....-...............--................................................. <br /> (Draw existing and required addition on reverse side) <br /> I 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 liters• <br /> sed agents signature certifies the following: I <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 bec��omsse.•sp feet to\W/ man's Compensation laws of California." <br /> Signed _! ! ...D .l...... ..- Owner <br /> i <br /> By - ....... __........................ .. -- ........ .......... ....... Title ...........-........................ . <br /> pf other the owner) <br /> - - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY,,... . ............. ........---------___.........._------- ........,.DATE._.: L.-. ....... i <br /> BUILDINGPERMIT ISSUED ..............................................--....................................--------- ...........DATE ........................................._. <br /> ADDITIONAL COMMENTS ............:................................_........ <br /> ..... _..._..-.-.-.......-........ -...- ..... <br /> ........................... <br /> ... ... <br /> __ ............... . ......... . .....�......................................... <br /> ..................._............ ........................ <br /> - ...._............... <br /> . <br /> Final Inspection by: ...... ............. ..-..-..-----------.........-_...--------.-.._.-._.-_.......... ' Date3'�. . '7 . -.------ ...--. <br /> EH 13 211 1-6(3 Rev. 5f SAN JOAQUIN LOCAL HEALTH DISTRICT 8�'7h 3M <br /> i <br />