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-`FOItOFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------------------------- ----- - - (Complete Triplicate) Permit No.. =1_ . <br /> ------------- <br /> Date <br /> ________________-----------------------------_------ -- This Permit Expires I Year from Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. j <br /> This application is made in compliance witl8o�nyOrdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS./LOCATION.--- <br /> C � -' <br /> ------------------CENSUS TRACT <br /> ,Q Q <br /> Owner's Name ll. .- - I -----------------------Phone <br /> ----------------------------- - - <br /> Address_ y�q-0 ...._._��''------------- ----------City- Zip 0------- ? <br /> Contractor's Name---. GJ.._-- v�+�-s --------------------------License #__c .7 �------Phone_ ''* _._ . <br /> installation will serve: Residence J—Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> J` Motel ❑ Other------- ----------- -- <br /> Number.of living units:-----(---------Number of bedrooms___4V.__Garbage Grinder------------Lot Size_--------------------------- _____________ ____________._.. <br /> Water Supply: Public System and name----.-------------3---------------------------------------------_-------------------------------.--- ------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ , Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam-E � C)1 <br /> Hardpan ❑ Adobe❑ 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: .(Nod septic tank or seepage pit permitted if public sewer is available within 200 feet,) y <br /> PACKAGE TREATMENT [ ] .' SEPTIC TANK -[r]' "" Size___s X�O_ --- Liquid Depth._ - ----___.__.__1�' <br /> . - Capacity:_A-04!------Type___r 6--y_--__-------Material_.---4-P -__-------No. Compartments----- - <br /> .2--q------- , <br /> 6 ! T Pro Line__/_-5- -------------- <br /> LEACHING LINE Distance to nearest: Wel!__..__�__U�__�_______________________:._Foundation__l__.___:____......__ . p. <br /> [�'��No, of Lines.___�----------------------- Length of each line._-- ---------------:Total Length -- - - -------__ -.-_--_=- <br /> 'D`�Box--,/-----^Type Filter Material- A`___-/i----Depth Filter Material------ -----------------------------------;------------- -. <br /> Distance, nearest: Well____�lg___-----_---Foundation____--� -______.__.Property Line.___!_______.___________________ <br /> SEEPAGE PIT [4+--- Depth._�S_.__.Diameter.;__ _____- Num --------- _._.__-______ Rock Filled Yes �No ❑ <br /> WaterTable Depth----------7-------------------- ------------------------Rock Size-- X ------------------------ <br /> 'Well <br /> ----------- - ------- <br /> Distance to,ne'arest`We[I.___�_J�_�f--_______________--__Foundation-_ _________.Prop, Line_ S__.___________._. <br /> 1� �_ <br /> REPAIR/ADDITION (Prev. SanitationtPermit#-----_------.- - - Date-------- <br /> --------------------------- <br /> 9 <br /> -__--_ _ __________________.___--M <br /> - --------------- <br /> i -------------- •--------- <br /> Dest'o dl Field (SpecifyRequirements)Reuirements)-'--�- ------€ -------�"-----------•----------------------- <br /> Septic (Specify <br /> ------------------------------- <br /> F ( <br /> ES <br /> _____________________________ -------------------------------- <br /> -______________________ <br /> t�. - _ 1 ---------- -- --- - -- - ----------------------------- y <br /> = --- = <br /> .i -. r <br /> (Draw:existing dnd required addition on reverse side) <br /> I hereby certify that I .have prepared this pplicati`on and that the work will be done in•.accordance with San Joaquin CountyOrdinances, State Laws, and Rules and 'Reg°ulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: 1�_Ij�t'his <br /> ..I�iertify that in the performance of the work for permit is issued, 1 shall not employ any person in such manner-as <br /> 5igned___ - - <br /> ------------------------------- <br /> Signed_ <br /> - -- ------- - ----� �aws�of California." <br /> - a-a-- <br /> to become sub"ect to W kman s Compensation - Owner <br /> By---- ---- --- ---- e------------------ ---- ----- itle - - ----- 1 <br /> E T - <br /> I It . <br /> (I. other thdn .owrier)�' 7; , <br /> FOR DEPARTMENT USE ONLY" ' <br /> APPLICATION ACCEPTED BY---1: - ----------------------------------=- -----------DATE ---------- :- - <br /> DATE.__��.�-�-- <br /> DIVISIONOF LAND NUMBER— --- -------- -- --•-------------- - --- ------------------ -----.--- ---------------------... - ------------------ <br /> h. ADDITIONAL COMMENTS--- ----------------------------- --------------------------,--------------------------------------- -------------------- ------------=---------- ------------------- <br /> ----------------------------------------------------------- --------- ----------------------------------- <br /> ------`-----------------------------------� -- ---- <br /> Final Inspection by:----_ C -------------------------------- -----------Date ------------ <br /> EH <br /> --- ---=EH 13 24SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. �i�e sM <br />