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FOR OFFICE USE: , 'APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> - <br /> ------_---'--------------------- -------------------- - <br /> (Complete in Triplicate) Permit <br /> --------------------------------- <br /> Date Issued.-Z/----J-/-- <br /> ---------------------------------- ---------------------- <br /> ssued._-1/-.._.._______________________________________________ This PermllflExpires 1 YeaF From Date Issued rt <br /> Application is hereby made to the San Joaquin Local Health District for a per it 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.---- (/ G --------.CENSUS TRACT_----------------- <br /> d <br /> Owner's Name- WOlrf Phone - - 3 <br /> Address --------------------------------------------------------- -------------------- itY----------- ---------------------------------ZiP--------- -------------------0 <br /> Contractor's Name__-------�.- _ /�?b ' .fid ---------------- --- icense #_f�`-S�"6-----Phone- 'z3� yl/'- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ SS <br /> Motel ❑ Other-------------------------- -------------------- <br /> Number <br /> - ------------ -Number of living units:------1------._Number of.loedrooms----]____Garbage Grin ___.______Lot Size____________________:_ � <br /> WaterSupply: Public System and name---------------------------------------------------------------------------------------- ---------------------------------Private ❑ <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 /> (Plot plan, showing size of lot, location of system in relation to wells, buildiqgs, 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,) <br /> Li <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] �i� � - __- _ _ ____ __ --------------------------Liquid Depth------------- _ ._ _ __ <br /> Capacity.._J­�',� Type.&y ��STMaterial _ _,4/C -.__No. Compartments.. x- _______.-_ ______-__� <br /> Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line___________________--- <br /> LEACHING LINE [ ] No. of Liriss-----------------------------Len tli of each line %;__�X � Total Length. y00 S <br /> 5 g ---- - <br /> 4 ;Poj Re4l 'D' Box- ______Type Filter Material_)O�L ____Depth Filter Material____ .z '*- <br /> Distance to nearest: Well----------------------------Foundation--------___________________ .Property Line-.______________________________- <br /> SEEPAGE PIT ( ] Depth_ _____ _DiameteK--------------------Number--- ---- __ ____ _________ Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth---`-`-=---------------------------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Welf�_---------------.__-__________________Foundation--------------------------Prop. Line_________-_..__________- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----- -----------------------------------------Date----------------------.---------------------) <br /> SepticTank (Specify Requirements)----------- -------------- ---------------------------------------- --------------------------- ---------------------------------------------------------- <br /> Disposal Field(Specify Requirements)---------------------- <br /> ---- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and-that the -work wi0 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 whit this permit is issued, l shall not,employ any person in such manner as <br /> to become subject to Workman's Compensation laws�gf--Colifornla." <br /> Signed-------- / -------------01.0"I" ------------------------------------------------------Owner <br /> BY - -------------- _--- - Title - - <br /> r. than owner) <br /> FORD TMENT Vp ONLY <br /> .APPLICATION-ACCEPTED BY- -------- - -- --- -----------DATE - - ------- <br /> DIVISION OF LAND NUMBE ---- - '- ----------------- -- ----DATE.-------------- <br /> ADDITIONALCOMMENTS------------------------------------------- -- ---------------------------------------------------- ----------------------------------------------- <br /> ------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------- <br /> - ---------------------- ---------------- ------------------------------------------------------------ -------------------------------------------------------- ------------ <br /> - - ----- -- ------ -- <br /> Final Inspection by:--------------------------------- __-- ------------ Date---------- <br /> --------------------------------------- <br /> t"- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICTFas 21677,REV. 7176 3M <br />