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w <br /> FOR OFFICE USE: <br /> APPLICATION-FOR SANITATION PERMIT FOR OFFICE 11SE:7 . <br /> •----- ---- -------- ----- ---- --- <br /> �--0 <br /> (Complete in Triplicate) Permit No.� <br /> _� <br /> ----------------------------............--•- <br /> Date Issued_ .5�. � <br /> ...........................--- ............ This Permit Expires 1-Year From bate Issued <br /> 9-3- Sao-L <br /> Application is hereby made to.the San Joaquin Local Health`District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/ <br /> LOCATION.......... (-xnGr--- <br /> - city <br /> � a:_-..1 <br /> Owner'V --)-!_--,-YW1_ C ..E�N—S <br /> -.US TRA.CT....../aMF Phone........ :........................... <br /> Address.... ie .-- ----- Cit . <br /> Contractor's Name. Lice -Z -- We...__....__.. <br /> Installation will serve: Residence I Q Apartment HmAe ❑ Commercial E] Trailer Court Eli _- _."`Motel ❑ Other.. <br /> i Number of living units:..__..--------Number of bedrooms-'...-.Garbage Grinder------------Lot Size.-.--. <br /> Water Supply: Public System and name.. _ .................. Private <br /> ----- --- -- ---- ------------- ---------- - ---.....--. -•----•----- <br /> Character of soil' a a depth of,3 feet: „ Sand . Sift Clay ❑•- Peat,❑_ Sandy_Loam�_Clay Loam ❑ <br /> Hardpan I p ❑ ❑ 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.) i r^ <br /> NEW INSTALLATION,: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,! <br /> -- ----------------Liquid Depth...5. ...__•..._ <br /> PACKAGE TREATMENT J ] SEPTIC TANK ]' Size ........ _ S_.- - Gy <br /> i <br /> Capacity:] Type__ �,''.Matev-ial_���:No- Co mpartments..... —--------- -- <br /> 1 <br /> I � I <br /> Distance to nearest: Well------- ---- -=--------- ---------Foundation----- ........Prop. Line--..UQ............. <br /> LEACHING LINE ` Lengtht! ! p ' <br /> ( ] No. of Lines } f <br /> -----_ _.:. of each line.. . + <br /> € � � - ---- - �'._�.... Total Length .. .�. --;'-- ---- <br /> D' Box_ ...Type Filter Material---- CBepth Filter Material..... ------- ! <br /> Distance to nearest: Well--(4­-.- ----Foundation..._1.( A ...........Property Line................................... <br /> Z <br /> SEEPAGE PIT ! <br /> - ------ --------------- e......---Rock Siz ...------......----......lad Yes ❑ No f <br /> Depth.... .. _Diameter.--•-----...._..._.Number------------------------------- <br /> Wafter Table Qepth------------------------------- Rock Filled <br /> Distance to nearest: Well---------------------- ------Foundation........-..---- ....Prop, Line..... <br /> .-.....-.---.--•--... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.----.---._---------------------- -------- - - Date---.-------•---..---.--.----------.-----------} y <br /> Septic Tank )specify Requirements).... . .............._._.....-- <br /> Disposal Field (Specify Requirements)_-------------------- ---------------------------------I-----_-- <br /> -----•---------------.. <br /> ------••--------------- <br /> . r [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 agent) <br /> signature certifies the following: 9 <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 a1 <br /> to become subject to Workman's Compensation laws of California." i <br /> Signed......... .. ------. ---- .... ----- -- .......Owner <br /> By....----- ..............Title.. ------ p._ <br /> i <br /> !f then than owner) f , <br /> FOR D PARTMENT SE ONLY <br /> ----- .- <br /> �5--] <br /> APPLICATION ACCEPTED BY__ .--•_.-----�.....---. _ DATE - . - - <br /> DNISION OF LAND NUMBER. . -- .......DATE.... ------------- --•---......-.. ------- <br /> ADDITIONAL COMMENTS-- -------- --- -- -------- ----- -- - ---- <br /> E - ---- ---- ........................... -------------- -- •--------------•--......--......-----------....---....---- .............--....--... <br /> --------------------------------- ------------------------------ ------- ------ --------------------....--------------....---...---- ..........--_.. <br /> ------------------------------ ------------------ - ----------- -------------- ---- <br /> Final Inspection b - Date.. _ %�:_ ._..... <br /> Y <br /> :... <br /> -------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FSS 21677 REV. 7 <br />