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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR,SANITATION PERMIT <br /> ------------------------------------------- --------- No...- <br /> (Complete in Triplicate) Permit . ......... .... <br /> ue <br /> ------­-------------- -- ----- -------------------- <br /> _ ._-.--.--__ _ This Permit Expires 1 Year From Date Issued <br /> ms's—iNho <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install he wor2G7 herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regul tions: <br /> JOB ADDRESS/LO TION 4'> - �- - -- <br /> --f-------------- - ---------,-- ------.CENSUS TRACT.-----`----------- ---- --- <br /> _ _ <br /> Owner's Name ; ;: - -------------------------------------------------------.: -----Phone-:----------=-------------------- <br /> dress- tP� �� ~l� = City zipS -��-- _---- <br /> s <br /> 71S�.3 S <br /> r ntractors Name---- .------ - --_--------- -- -- --License #--------- -.--- ------Phane-7--------`------.----------- <br /> Co, <br /> I Installation will.serve: Residence Apartment House E] Commercial ❑ Trailer Court.L] }: y <br /> M Motel ❑ Other---------- --------------- <br /> Number <br /> -- <br /> Number of living units:____._ ____Number of bedrooms_._=.____.__Garbage Grinder. _ Lot-Size______ <br /> i Size ___ - -----C._� <br /> Water SuPPIY� Public System andname .- ------------------------------------------ <br /> ------------ <br /> J y� <br /> -_.------------------=----.--- ----------------- - <br /> - --- --:- `Prvate <br /> 4 ! <br />! Character of so![ to a depth of 3 feet: . Sand ❑ Silt E] Clay`-❑; Peat ❑ anLoam ❑ Clay Loam f �ry <br /> - <br /> Hardpan ❑ <br /> Ad-'be Fill Material._.__.__ _ _If yes, type.----_.---i___________________ _ <br /> a � <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 Zr seepage-pit_permitte&f publ-ic-sewer-is_avaiIable within 200 feet,) , <br /> r r <br /> i PACKAGE TREATMENT [ J SEPTIC TANK Size14/ <br /> r-_----�,5!_X_- ------------------_-_Liquid Depth.______-_._____-.___--___-- <br /> Capacity .o �aa_____�Type � ' �d'f__Material_ ` ----------No. Compartments.__..__,.._ -------- <br /> or <br /> nearest:.Well.'.-����_.:-_ _--rte=._.___Foundation.--./------------------Prop. Line__6 ... A?._____ <br /> LEACHING LINE, No, of Lines--- .,.,:-_,__._____Length of each line_45�__ �_:_ U._._ Total Length ------;;-;217___-----------------**- <br /> D' Box--- Filter Material_31? .Depth Filter Material------ _------------- -------------------- <br /> {. <br /> Distance to nearest: Wel!_/d401-------- ----Foundation---R41-`--------- <br /> Property Line..._~ ________________ <br /> SEEPAGE PIT `�t ' <br /> [ l = Depth----------------Diameter.=----=----J_.____-.Number---:------:_----_---------____-- Rack Filled Yes.[_ No ❑ <br /> I Water Table`Depth.: - ; <br /> ----------- ------ - Rock Size.---- -=---------------------------------------- <br /> i Distance to nearest: Well---------,-----------------I-------------_---Foundation-- ------.--_-.-.----._-.Prop. Line._.-._.__--____---.-_.- r <br /> 1 <br /> REPAIR/ADDITION {Prev. Sanitation Permit#......:-r----------------------F___.------:------Date_ <br /> ----,------- ---------------:---:-------------) <br /> i 3 <br /> Septic Tank (Specify Requirements) -------'---- = ------------------ ------=----------------=-------------------------'---------------------- <br /> 1 <br /> Disposal Field (Specify Requirements)---_-----____„_-_,_ ___ . <br /> i ----------------------------- ------ -- 1 ------- -- ------------ ------------------------------------------------------------------ ------------ <br /> -- --------------------------------------------------------- --- ------€--- -.--- ----------------------------------------- ------------------------------------ -- <br /> - --------- ------- <br /> (Draw existing and required addition on reverse side) ' <br /> hereby 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 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 gas <br /> Signed -------- -- - --------------------------- <br /> By <br /> ---.-- -- - -- - - --- :-s of California.” - ,.• -_:-._� . .� �' <br /> • NI--.--- Com nsation law - <br /> to .become .su to or ma <br /> P <br /> g� - - c----- - Owner <br /> Title.-- <br /> E BY-------------------- -- Lam/ . t <br /> i (If other than'owner) .. . <br />{ f FOR DEPARTMENT USE ONLY <br /> k APPLICATION ACCEPTED BY-- _ �, _, a =...................... <br /> - ---- - ------`----------- ---------- ---DATE./.Z_�./?- ------------- <br /> E DIVISION OF LAND NUMBER______________________ t _ <br /> = = DATE <br /> ADDITIONAL COMMENTS--------- -------- -------------------- ----------=------:--------------------------•--------------------------- -------•---------•--- ------• ----1--- <br /> - <br /> } <br /> ------------------------------------------------------- ---------------------------------�---- ------ __ --- ---------•------------------------r--r------- --------------------------------- <br /> F Final Inspection by:-- = __ = - = -.Date 7 _ - 0--� -- <br /> -------------- . <br /> I EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 21677 REV, 7176 3M <br />