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-' FbR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> `� Permit No...�c <br /> �ci �(�mp}' to in Triplicate) <br /> ---------------------------- <br /> --------- Date Issued......... �4 ­ <br /> ....................... ----- <br /> ........--. <br /> „.................................._ --.. .-..- I 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 o-s made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ...........-..CENSUS TRAC :... ... <br /> JOB A�l2ESS/LOCAT ON. .....L. L-��.../-✓..may/9�- ,4/-�q <br /> /f L.=.. . . .�%s_SP,ci ...... .. . ..... .......... <br /> Owner's Na e.__. _. _ // .... ... ..X71e— <br /> � ... /fl . ttTT �Cr <br /> Address_._.. ....... .. ....�j�- .. ------_------------ . ......._....- City. <br /> Contractor's Name---- °...... License #------- Phone.. = =------ - <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ( Trailer Court ❑ <br /> Motel ❑ Other------- • .... ..... <br /> p....Number of bedrooms-...-.--. <br /> a-- <br /> ge Grin'de.S.T-...-......_. Size... <br /> :0. s,Number of living units:... --- --/ PrivaPrivate Supply: Public System and nameg G ..et_-.a <br /> --- .... <br /> Character ' <br /> ' <br /> 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 /> (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,) J1 <br /> PACKAGE TREATMENT ( ] SEPTIC TANK Size.... -7-7l4D......4+/ --_Liquid Depth-------------- -----------4 <br /> Capacity f20o Type.-Po.CZ. ..Material._. .Q .....No, Compartments.------ ?-"---------- ..�-- <br /> Distance to nearest: Well--.... -- ........ .........Foundation..--- d .- -. -Prop. Line.......5 --------F <br /> LEACHING LINE +CL No. of Lines .........v?_____.-.-...Length of each line..----... .- ...... Total Length .. .-_-- Q---------------- <br /> 'D' Box...yXS---Type Filter Material:_.�'t.''aW' 'e../...Depth Filter Material_-----------1-v-- ---- --------- - -- ---- ----------� <br /> Distance,to nearest: Well-.All....---....------ Foundation. '` ��... ..----Property Line..._.. <br /> SEEPAGE PIT ( ] NAPepth................Diameter...............-....Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth------------------•----------------. - ------------Rock Size------..... -. ----- - <br /> Distance to nearest: Well-------------- -------- --............Foundation.....................-.-. Prop. Line------------_-----------... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------- ------ ----------- --Date.--•------..---....---......----....--- ------) <br /> Septic Tank (Specify Requirements).......................... --------------------------------------------- <br /> - <br /> ( Disposal Field (Specify Requirements).____............. ---... . --- <br /> -•-------------- ---------- ..........................---............ ----------- ----- <br /> (Drow 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 agents <br /> signature certifies the following: <br /> "1 certify that in the perfqgnance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become su . kman's Ctom en ation laws of California." <br /> Signed. ---Owner 3 <br /> By.......................................... ...... _Title ----- ------ ----------- ......-........................... <br /> (If other than owner) T <br /> _FOR DEPARTMENT USE E:11ONLY <br /> 11234 <br /> APPLICATION ACCEPTED BY f. .. -- .................. DATE __., _ (o ..'7 °J:. _✓.J <br /> DIVISION OF LAND NUMBER'.....--- -- --- --- -------- .................... DATE.._._...--------- --------�\ ------ --- <br /> ADDITIONAL COMMENTS ... od, ���r�-- — 4--- - i+,ri�.--.. A-I' ktL�47r0 � -fp- Y�2!"S+ ....... <br /> ��!'4 <br /> ...... <br /> .- <br /> i Final Inspection b <br /> ------....Date .... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT fas 21677 ( 7176 3M <br />