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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 9_ <br /> ---- -------- ------- ------------------------------- 9 - 8 3 <br /> {Complete in Triplicate} Permit o.. ............. <br /> --------------------------------------------------------- <br /> Dote Issued <br /> i' ------ This Permit Expires 1 Year From Date Issued <br /> E <br /> i 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/LOCAT N._. ! _9- ----- _ 11 -ter. ----- ------ ------ --- - -- CENSUS TRACT '... <br /> t / . <br /> Owner's Name t !/-- -- --- - --------- -- - -- ------ ---- ------------ ---Phone ----------- ------- -- ---------------- <br /> ------------------------------ <br /> L <br /> - ----------- <br /> ._ <br /> Address- <br /> _. -City _ Zip <br /> ---- ------- <br /> .- / [ s <br /> Contractor's Name--'----- ,iG -`c r i :License # �-- -�----Phone---- <br /> Ins'talla#ion.will serve: Residenc" Apartment• House ❑ Commercial ❑ -Trailer Court. ❑ <br /> .i- Motel !] =Other._.: _ <br /> Nuymbe'r of livin un€ts_______1Numbero� fbedrooms;_._____- Garba a Grinder. <br /> of Size---g _____ <br /> Water ' <br /> Supply: Public System and name--- ------------- -_ =-_-- --- --- =-------- -.------------------------------ -----------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ iSilt :Clay ❑ . Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> s, . <br /> Hardpan Adobe.❑ Fill Material------------!f 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'#ank or seepage pitpermitted if public sewer is available within 200 feet,[ S <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [`] Size-----------------------------------------------------------Liquid Depth----____------ ------`---- <br /> t <br /> Capacity------------------=r TYPe `---= = = _ __Material = " = No. Compartments = - ='. <br /> . it�--" <br /> .Distance to nearest:,Well____-0-------------------- u:-= _.____.IFoundation-------------------•--------Prop. Line-----------------------+---. <br /> LEACHING LINE [ ] No. of Lines_:___-___ _,_ ' __ 'fLerigth of.each I_ine._..I______________ _,.___.Total,.Length _.-_________________________.__._-__ __ , <br /> J _-Depth Filter Material <br /> D' Box__--., _._.._Type Fllter-Material __-.-- -=------------ ----- --------- <br /> ' <br /> ----------------- <br /> `--------------= Foundation. Property Line <br /> Distance to nearest: Well'* <br /> € - <br /> SEEPAGE PIT [ ] Depth----------------Diameter_:_"__..i, <br /> --------Number______________.._____________ Rock Filled Yes ❑ No ❑ <br /> P -----`_------' ------------------- <br /> ------='•-r�-------=--------------Fo R dat oln�:--------------------- - - . <br /> Distance to nearest: Well_..____._ /� - <br /> Water Table Depth <br /> __ Prop. Line------------------ ----' <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------------------- --_1Date--------------------° r _ _- ----). <br /> S <br /> Septic Tank (Specify Requirements) = - -- -- ---------------------------- --- ----------------------- ----------- <br /> Dis <br /> Disposal Field 5 <br /> ped Re uirements _._____ . - 4 <br /> P ( Y. q 1 .. - - --=�---.�-- --------- ----- <br /> -------------- <br /> f e /.F <br /> ------------- � ... - .---- = <br /> E - ---------- <br /> lDraw existing.and required addition on reverse side) <br /> hereby certify that I have prepared-this.application and that the .work will be done in cdccordance 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 followings ' <br /> I "I certify that in the performance 'of-the work f6r wh€ch this permit is issued, i shall not'eMploy any person in such manner as <br /> I to become subject to .Workm 's Compensation laws of California." I <br /> 1 <br /> Signed- ---- ----- = ,Cwvnar z <br /> t <br /> € BY------ - ----- --------------- --- ----- - Title- <br /> (If <br /> : • <br /> (If ofher than owner) - <br /> .� ' 1 <br /> OR DEPARTMENT USE ONLY <br /> —APPLICATION ACCEPTED BY --,--- - ---------------------------- - `------DXTE.=S= <br /> DIVISION OF LAND NUMBER..---- -- ---- - -= ----I---------------- --- --- - ------------- ----- --DATE.-------------- --------- ------------------€ <br /> ADDITIONAL COMMENTS----------:------- ----- --- ---tiff_-:^_ _ 4 <br /> -----------------_---_-------_ _ ______________ -------------------------------------_--------------------------------------------------------------------------------------_----------- <br /> --------------------------------------_ _ _.__._.___.______--____________.__ ________________________.________.__.--------------Z: __ _ _________ _ __---------------------- <br /> I ---------------------=---------------------------- - ------ -------- ---- ---`---------- - - - <br /> -_ ..._ <br /> Final Inspection by-- --- .... •c� - ---. --- ---- ----`-- ---------'-------------------------------- ----Date--- --- -- <br /> EH <br /> � <br /> i' EH l3 2d. F&S 21677 REV. 7/76 3m, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />