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. -30t,006 tcn.sso � �--�-� _ <br /> FOR OFFICE USE: �' €OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.__-__________ ______ <br /> qZ I 1 Date Issued--- <br /> ---------------------------------------- ----------- <br /> __________________.__________________.___________-__ 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION--)--F�----51?^r74---C'irc4c------------�.a--- l3 >------ CZ_" .CENSUS TRACT---------------------------------� <br /> Owner's Name--------------- / a--5------------ - ------4r i//V - - Phone _'1r - 3''7 99 <br /> -------------------------- <br /> Address..---30J_QOO ? -/35 S6 t - - Ci T�.v c <br /> tY----- - Zip----------------------------- <br /> Contractor's Name------45,4irj------- X---d---Sam✓--- ----- -------- ----License #---/G6 -556-----Phone--_-- -T------/---Z--/--- <br /> Installation will serve: Residence® 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----------------- --------- -----------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam t <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth ______�___� <br /> J2aa Oye C/.s% �b/1/G - <br /> Capacity - TYpe = Material--- - --- --------------No. Compartments--------- --------------------------'Q <br /> Distance to nearest: Well___________________________________________Foundation___.__-/__o-------------Prop. Line.___`^_.__._____________. C <br /> LEACHING LINE [ ] No. of Lines---/:"Ire�___Q��Length of each line-- �-X_��_`_____..Total Length.-_____.__-___------------_-__----__� <br /> 'D' Box-----I------Type Filter Material Rc CR__-___Depth Filter Material____ _a_- � J� <br /> - - <br /> Distance to nearest,-Well---------------------------Fo-undation------f-G---- -- --------Property tine----15-------------------------------- <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 /> SepticTank (Specify Requirements)------------------------- ---------------------------------------- ---------------------------------------------------------------- --------- <br /> Disposal Field (Specify Requirements)---------------------- -------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------ ------------------ <br /> --------------------------------------------- ----- - ---- - -- <br /> (Draw 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 Son 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-----)E', -/----N---�- -�-o�----------S-------/------------- - <br /> ------------- --------------Owner <br /> BY Title ------------------------------------------ <br /> ------- <br /> --- <br /> S ----------------------- <br /> (If <br /> ------ <br /> (If other than owner) <br /> FOR D TMENf E ONLY <br /> APPLICATION ACCEPTED BY-_ _._ ---------------------- <br /> DIVISION <br /> 2 <br /> --------------------------DATE. ------------------ <br /> DIVISION OF LAND NUMBER---- ---------- -- ------- ------------------------------------------------------------.DATE-------------------- ------ <br /> ADDITIONALCOMMENTS-------------------------- ---------------------------------------------------------------------------------------_-------------------------------------- <br /> ------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------- --------------------------- ------- <br /> ------------------------------------------ - -- -------------- -------------- -- ---------- <br /> �----- ---------------------------------------------------- ------------- -- <br /> Final Inspection by:----------- E - Date---- ------ -- <br /> EH is sa SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7176 srn <br />