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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ........................................ <br /> (Complete in Triplicate) Permit <br /> ---------------------'--- I Date Issued--/'7rl0_-.7/1 <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: j <br /> JOB ADDRESS/LOCATION --- ... -� �` j .1C?................... ..------------------------- .....CENSUS TRACT...------.--------------- ...... <br /> Owner's Name �pp 1.. •---------------------------------Phone <br /> r 1 _ <br /> Address... ------ --- --------.----------_ ----------- ------- .... . - ----------- -- City .l`/ / f ---- .......zip -:-----•--- -- ----------- <br /> _.. <br /> Contractor's Name--- --...' F /f �. >.✓ --- ....... -...License # / . .Phone. -/.... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> 'Motel ❑ Other------ ---- ---- - --------•-- ' <br /> � ,J f <br /> Number of living units:... .........Number of bedrooms..-A Garbage Grindw...._.......Lot Size----- ------.---- <br /> Water Supply: Public System and name-------------------------- -- Private <br /> - -------•------------------------- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ `Peat [],,Sandy Loam X Clay Loam El <br /> Hardpan ❑ Adobe ❑ Fill A terial'-_'i"._. ---.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,p Size <br /> if public sewer available within 200 feet,) <br /> �. Z �-^-- / <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ...................Liquid Depth._i�--,��-.----.------- <br /> 'Capacity.l Typef1_j)4!!�:.,70Q'rMaterial No rC-ompartments. = `'�I... <br /> * Distance to nearest:,WeEI-------. 7�.-.......-..---.......----....Fodation---/-Q. . ...... ..... Prop. Line <br /> LEACHING-LINE j j No. of Lines .- � ?�+-• . . 7 Length of each line. -- ----------- ---Total Length .......... <br /> 0,0 <br /> , % <br /> 'D' Box--1 -..�--Type-Filter Material_I0.,Yca'2. Depth Filter Material-- ............ "----.----------------- - ---------------- <br /> 4 - <br /> --- - ------ <br /> Distance to nearest: Well...5 -. ..__..,.....Foundation----- �-� Property Line.... .. -------- ----- <br /> t <br /> SEEPAGE PIT [ ] Depth... .... ----.Diameter--------------------Number.------------------------------- Rock Filled Yes ❑ No ❑ <br /> i. Water Table Depth---------- ------ ------- ........ ----.------.Rock Size-- - ........----_-------------- <br /> t <br />' >Distance to nearest; Well------------------------ -- -....---....Foundation--------- ......Prop. Line------- - - ------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#..-_--------------•- ------------. . -- •--. Date------•-...._.....-__...... -------} <br /> Septic Tank (Specify Requirements)- . . ----.....:----------•--------- ------------- ----..--...-.... = ------------- -- -......------ ----=---------- - -- -------------- <br /> jDisPospal Field (Specify Re uire�m�e_ <br /> nts1-.. .. -:-•-- - <br /> ----- ...... ------------------ <br /> - <br /> -----------•---------------------------------•------------ ---------------- --------- .----------------•------------ -------- <br /> --...... . ......--- --- ...--------- <br /> (Draw existing and required addition on reverse side) <br /> I heteby 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 'Son 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 subject t Wj> man' Compensation laws of California.” <br /> Signed.- f._.. ✓ -----Owner <br /> `.. .. .............. <br /> By---------------------------------------------------------- .Title-------- .................. ------ <br /> (If other than owner[ i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- - .... _. . .... .. . ----.......DATE .Jam.... <br /> DIVISION OF LAND NUMBER. ......... .-.---DATE.--- --------_----- ------ ........... <br /> ADDITIONAL COMMENTS. --- ---------.I:.. -•- -- ........... <br /> .........� ..__.,. .._................... ... .- <br /> - - .. . T.. <br /> --------------------- --..... - ------ -- ----------------------------- - ---------- _... <br /> k <br /> ,.. - ..- <br /> Final Inspection b .....Date.-- --- - �- <br /> 1 fH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 716777 <br />