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FOR OFFICE USE: (rj FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> V <br /> ------------ ---- - - - - ------- <br /> (Complete in Triplicate) Permit <br /> / 2:a0 hla0rf 1_. <br /> ......................................-+—._- <br /> ��-- Date Issued.//._.3.-J-.-- <br /> .................._.----...----.... .......----... This Permit Expires 1 Year From Date Issued <br /> i <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 /> JOB ADDRESS/LOCATION. ._- p d°� �t "Z"Le_ ---------------.CENSUS TRACT__.--•------ -__--- <br /> Owner's <br /> -- _-- .-.-. <br /> Owner's Name , ---------- p -.-- .-... Phone.. <br /> ......... �..... <br /> ----.--.. city <br /> --;---------. -------- <br /> Address.../12-Yo_C2_ ------�---- ------ --zip <br /> .... .._License Name--------- ---------- Phone..... <br /> Installation will serve:'""" - ResidenceX Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- --------------- <br /> Number of living units:.--.-- -----Number of bedrooms .....Garbage Grinder--.--...-..-Lot Size.--. /. .. ... ............ <br /> Water Supply: Public System and name.................. <br /> ---- ----- ---------------- -----•-------.Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay 0 Peat ❑ Sandy Loam ❑ Clay Loam ❑ I <br /> Hardpan X 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.). i <br /> NEW INSTAL;ATION: (No septic tank or seepage pit permitted..if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT <br /> f ] SEPTIC TANK [ ] Size.,..., - ..... - ------------=--------------- .-.-Liquid Depth.-----:-----...--- --- ' <br /> Capacity---- --T e--__.-- .---_. .-....Mate•rial-.-------- ---No. Compartments----- -- --------_-- <br /> i <br /> Distance to nearest: Well---------------- .........Foundation..---..--. . ....... Prop. Line-------------- --- ------- <br /> LEACHING LINE [ ] No. of Lines <br /> - -- - -- ---- • - . Length of each fine------ ----------------------Total Length .. . -------------- -------.-..-..� <br /> 'D' Box............Type Filter Material... -------...--..Depth Filter Material----------------------...................... ......------------ <br /> -Distance to nearest: Well---------------------------.Foundation-------------------- - -----Property Line--------------.------------------- <br /> SEEPAGE PIT [ ] Depth-- -------- Diameter-------------------Number--------- -•------ Rock Filled Yes ❑ No <br /> WaterTable Depth-------------------- -•-......------- ......-------• -.Rock Size--............ ---------- ---------- <br /> Distance to nearest: Well-------------------------------- ----Foundation....------................Prop. Line-------.--.--------...-...-. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----------_---------------------- -----..........Date---------•.................... <br /> .--- -----------] <br /> Septic Tank (Specify <br /> Requirements) <br /> %- <br /> --/ <br /> Disposal Field ( ecify Requirements) J!/ <br /> J <br /> ----------- - - -------------- <br /> (Draw existing and required addition on reverse side] <br /> I hereby certify that I have prepared this applications 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 /> "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 /> to become s [ect to Wor . an's Compensation lows of California." <br /> Signed-•- ........ ..... ------ -Owner <br /> BY-------------------- -�� -��!/ ---- - .- ....---•-- ...-----.... - -Title-----...- -- -�---------- -- - --- <br /> -- -- ----- ------ --- <br /> (If other than net) <br /> r; <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY................ J ------- .. ---- ----- -DATE ------- ........... <br /> DIVISION OF LAND NUMBER.-- ................. ----.-.DATE---------------- -.--.- <br /> ADDITIONAL COMMENTS. ----------------- ---- - ---...... --- - ------------ -- -- ----... <br /> ------------------------- . ..................................... . ................................................ ------------------------------------ ----------- ............. <br /> ........................................ --- .... - <br /> FinalInspection by:.-.. ..... ... -- -- ---------------------•-------------------------- -.......--,......----- --..-.--.-. .-.-Datell. 0 .... <br /> ras 2577 REV. �i�e 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />