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4 <br /> FOR OFFICE .USE: R OFF USE: <br /> 41, /� APPLICATION FOR SANITATION PERMI <br /> ------------------- - <br /> - (Completeiri Triplicate}_a Permit No....f1J <br /> -Date Issued- <br /> ------------------------ ------------------ ..... -- This Permit Expires 1 Year From Date Issued <br /> • � <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 OrdinancONo15d9 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION------- /O" -- --- .-- -e-- -G .gtij US TRA - <br /> Owner's Names i1 _YiglL G - ------------- --GENS one - -- -- ----- '-- <br /> CT __._ <br /> ,r ,. . <br /> -------Ph ----� �- -------- <br /> Address �rIs<Ju? fib- `6_%i¢,V�aS_ <br /> C <br /> i <br /> Contractors Name-- ----_ _ ,# k <br /> #.. p_ = ----=------=--- --License : .--�-----� -- -_------` Phone--- <br /> Installation,will serve: 4. Resi Motel # ' <br /> t ❑ <br /> dente A artmenf House ❑ Commercial ❑ ;Trailer Court ❑ t <br /> ... ..__ .. F Other -i--- --__ ---___ - <br /> . <br /> r . <br /> Number of living units:.-_-__-__ __ Number of.bedrooms',c�Z:.__ Garbage.Grinder'�-t __':Lot,Size___ ' _.-__i..... <br /> Water Supply: Public System_ and name____-._ -_-- __ <br /> p �._ � ,.. ❑ � Y ❑ Peat❑ Sandy - -� .------------------------- <br /> 7Private�❑ <br /> Character of soil to a depth of feet ; Sand Silt Cla Loam` 'Clay Loam ❑ <br /> Hardpan Adobe Fill Material-_..._.____.Ef'; es, type <br /> { ❑ Y YP ------------------------------ <br /> (Plot plan, showing size of lot, location of sysfem in relation.toTw-el.ls,_b ld•ings-•etc, must be placed on revarse�sid'e.) ! <br /> NEW INSTALLATION: (Noes ptic t nk:or seepage�piit permitted if public sewer is%vailable within 200 feet,) <br /> PACKAGE TREPATMENT�;[ ] SEPTIC TANS,r[-I] ___"Liqu'id Depth F :_ <br /> l : <br /> C-apacity_7=4- ---+-•----Type--- -�A?laterial °h-` _:_No: Compartments.-:-- ------ <br /> . Distance to nearest: Well -------Foundation. 4C�� ----- Pr6p."Linea <br /> .f Lines ' __ Length ofeachU __ Total LengthLEACHING LINE No _ 0` <br /> D' Box............Type Filter Material• _ ________ ------Depth FilterWatedal G r --A <br /> Distance to nearest; 11VeIl : oundation_"__ fi--- Property Line_.�P � <br /> --- <br /> 4 E <br /> SEEPAGE PIT [ ] ; Depth-_:------------Diameter_ Number------------- --- __ Rock Filled Yes ❑ No 0 <br /> Water Table Depth ]-----------------------------------------------------Rock Size 6 � <br /> Distance;to nearest: Well----------- <br /> ------------------- _----:Foundatiori_]----_-:_-- -- ----". Prop. Line------------------ -----ns <br /> REPAIR/ADDITION (Prev. Sanitation Permit ---------------:::-;__----------- <br /> ----------- <br /> Septic <br /> ----------Septic Tank (Specify Requirements) --- ------=-=---- ----° ------------------------------------------ : <br /> Disposal Field (Specify Requirements)------ ------ ---- --=------ -------------------------- <br /> ----- ---------------------------------------------- - ------ ---------- <br /> -------------- - ---- ---- <br /> (Draw existing acid required addition-on reverse sided r <br /> f <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 agents <br /> signature certifies the following: <br /> l <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 s to rkmanrs ponsation,Ic f California.',' £ } <br /> 1 . <br /> Signed-=--- _.. .� ' ----------- <br /> ---Owner <br /> By-1----------- --- ----- ------------ =---- Title----- --- <br /> .. _ <br /> �. <br /> (if'other than;owner) <br /> { FOR DEPARTMENT USE ONLY. , <br /> APPLICATION ACCEPTED BY----- <br /> -------- ------------= - DATE._j.Z. r <br /> DIVISION OF LAND NUMBER. - - ----- -:--------- ---------------- ---DATE..'------------ -------- <br /> ADDITIONAL COMMENTS--------------------------- <br /> ----------- .----- -------- -----• ---- --------------------:... -- ... ........................ <br /> ----------------------- ---- ----=------------------------ ----------------------------------------=---- --------------------------- ------------------------ <br /> ----------------- ------ <br /> - ------------------------------------------ ------- ------- ---------------=----/----------------------- ------------------------------------------ --------= �s <br /> Final Inspection by------ =- - ----------- =---- - - ------ <br /> -------- =` = = '' ,-.,.-.. . ------------ Date =-" , O _ t <br /> EH to 2 SAN JO QUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 176 3M <br />