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FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �j <br /> i.._....'_.. Permit No....X!--.--- <br /> (Complete in Triplicate) <br /> ------------­............................ ------ - <br /> Date Issued_., ..._.... <br /> ..................... ... This Permit Expires 1 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. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> _ ----.CENSUS TRACT... .'... <br /> JOB ADDRESS/LOCA N_..�,j --.... -5�-J�,/��✓�-11/1��-------- ------------ -•- <br /> • �� `, <br /> Phone- 3...... <br /> Owner's Name:- -.-. .... .. 1C�1 <br /> _..._Ci d-------------------------Zip.•-=--......- ---....__------- <br /> Address��.. 1�-.. /��/.../1�r .�` <br /> Contractor's Name-------.. --- � '/� �{� drltC�............... ...........License #.�1��.���- .Phone. �, <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Fr1railer Court ❑ '. <br /> Motel ❑ Other_--- ----- --- ---- •••-•---- <br /> Number of living units:......__--------Number of bedrooms....._._.... bage Grinder_.-.--------Lot Size--__..------.-. _---•--- <br /> - Private _r <br /> Water Supply: Public System and name............. .... . ..... ........ .�/ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ _ <br /> 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �y <br /> Depth--- ----------- <br /> PACKAGE TREATMENT SEPTIC TANK ------- Liquid ---•--- <br /> aterial.................. NoiCom artments.Capacity ``200--- Typ [ � <br /> f e Foundation. Prop. Line --- -------.9 . <br /> Distance to nearest: Well--- ---- <br /> LEACHING LINE [ ] No. of Lines ...---..- --------------Length of each line.._..-..r.f /-.......... <br /> -- --- Total Length .. ._ �----------------------• �}- <br /> D' Box.......V Filter.Materi <br /> i'" a5; ..r/C-_ Oe�h Filter Material.._ ............ . <br /> Distance to nearest: Well.............................Foundation_.:--------- rt'-- Property Line.-.-----------------........... <br /> SEEPAGE PIT ( ] Depth_...`:..-- -----Diameter................... Number_------------------------------- <br /> Rock Filled Yes F1 No E] <br /> .� .,-- <br /> Water Table Depth---------- ........Rock Size.....-- ..... -=------------ <br /> Distance to nearest: Well---- ....--.........Foundation+............. Prop..Line ---- --- __- --------- <br /> ` 1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------- ------ ----------- ..�Date....._-- ------------- .... l <br /> Septic Tank (Specify Requirements)---- -------------- --.--------------------------------- ------ <br /> Disposal <br /> i ----- .... : -.... <br /> Disposal Field (Specify Requirements) ------------- r ' <br /> �°------- ------ ----- ---- -- ---------------. <br /> - ---------- <br /> - <br /> ----------------------------- -------- •-----..... ------...------ ---------•----..----------------- <br /> ,� -_------ ........ ------ - --- <br /> (Draw existing and required-addition on reverse side) <br /> i' t hereby certify that I have prepared this application and that the work will be done in accorclbnce`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 /> i to become I to Work an'sCom a satiore laws of California." � <br /> / 9 ....--Owner <br /> Signe `- ---�� . <br /> .._ ....Title.-- L..__... <br /> i (If other than owner) <br /> FO DEPART S NLY <br /> APPLICATION ACCEPTED BY-:----- -- - <br /> k --..DATE ------ - -- <br /> DIVISION OF LAND NUMBER........ ...... ....... .... . ---- -.:. ----- <br /> DATE_..: . . -- ....... <br /> ADDITIONAL COMMENTS.- ------ --------------------------------------------- <br /> .�-_.. .-- --- -- ....._. ...----- <br /> •--------•--- <br /> '{ ----------• ------------------------------- ----- ----------- ------•• — ----------------- ---------- -------------------------- <br /> ' Final Inspection b ............ ...Date ......................--------- ------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas sib» eEv. 3M <br />