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FOR OFFICE USE: _ <br /> .�----- FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------- --------------- ------------------ Z" GG <br /> (Complete in Triplicate) Permit .No--- <br /> ------------------------------------------------------_- This Permit Expires '( Year From Date Issued Date Issued___,--k_-_>/ <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 .--(l � --- AA ------------------ --------------------------CENSUS TRACT----------- <br /> Owner's Name-.------------ = wG - c -7 <br /> Phone-- .-�7_---- - <br /> Address t - 'Par =1 ----� ----------------City slip - <br /> Pte: :: <br /> , � ' <br /> ! '� '7 / -- -----------License # :" Phone_, �' � <br /> Contractors Name ------- --------- --- -------- --- <br /> `v, Z-, <br /> Installation will:serve: Residence>d i Apartment House-❑ `Commercialer'❑`TrailCourt-0 ; <br /> -. ❑ <br /> Motel Other --- - ,. �1 . <br /> Number of living units:-----.- _Y--Number of bedrooms--_�---Garbage Grinder------------Lot Size------:1L.Z.-�1�L .. <br /> Water Supply: Public System and name---------------- ----------------- <br /> I " - I ❑1 - Yom : � y 'I 0 - y o <br /> Character of soil to a depth of fee❑t:__ Sand �}f ye'�typV _,.�y__ �- Loam" p ❑, Silt Cla Peat Sand Laam Cla Lo f <br /> Hard an Adobe FiI'b:Material_ <br /> f U L` <br /> {Plot pian' showing size of lot, location of system in relatioiiifa=wells, buildings, etc. must be placed on reverse side.} 1 <br /> NEW INSTALLATION � .(No septic tank dor seepage p}t._ ermitt.ed_i.f_p.ublic sewer is available within- 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size--i -------- Liquid Depth ---------------------- <br /> ---------------------- <br /> f ' <br /> --- <br /> Capacity----- �-- = = Type _g --Mafe�rial ------ - ---No. Compartments . <br /> �•- - i F . <br /> i Distance to nearest: WeIL--------)--- ------------ -`'-:------t---Foundation:-------------------------Prop. Line-:------------------------- <br /> -. <br /> LEACHING LINE [ - p <br /> I j . Na. of Lines Length of eac}Mine= =--------------- :.Total Lengfih. ----------_--------- <br /> 'D' <br /> --- --- <br /> til i � ' . <br /> YP °..Depth Filter Material =-----------F----- ------------------------------ <br /> Distance:to nearest'WeIL!__v�-----1-- y ��" -`" T" ' '°�"� <br /> ' Box------------T a Filter Material-------------- <br /> F t` ' Foundation .Property Line---------. ----------------------- <br /> SEEPAGE PIT p �, € - - <br /> I l De th---- -- - -Di meter ------:---- <br /> Numb"er_•s_----------- :- Rock Filled Yes ❑ No ❑ <br /> 1i Water Table pih--------------------- 1---"- - ---- _\----`------Rock Size---------------------------- ----------------- <br /> Distance to nearest:WeIL-:..'_' +-,-- _---_ �__�`'Foundation------------------------..Prop. Line-:--------------------- --- <br /> F <br /> REPAIR/AD ID TION'(Preva Sanitation Permit#r -� "} --:--sl-f- --_--"----------- --- Date------ --- ------ ---.------------) <br /> ? I }/ <br /> Septic Tank (Specify Requirements)--- <br /> Disposal Field (Specify Requirements)_--- - �f --- - ' <br /> -----'------------------- ---------=------------------- <br /> ---------------------------------------------- <br /> i ---- ---- f <br /> - - <br /> (Draw existing a6J required cdd.ition',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 Distract-Hometowns or licensed agents <br /> signature certifies the following: <br /> "I certify that in t�eperformance of''the work for which thisper' mit is issued; I shall not employ any person in such manner as <br /> to become s01Qpc0to�_Workinan's Compensatio-n law,df California." <br /> Signed- ------ --------- <br /> --- Owner <br /> By-- - --- -------- -------- ----- ---- ----------Title-----=------ --- --- <br /> ------------ <br /> (If other than owned I <br /> } FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- -------------- ------------------------------------------------- DATE.------ <br /> DIVISION OF LAND NUMBER ---"---- --- --- --- ----------------------------------- -:- ---------=------ - <br /> t--------------------- -DATE-- ----- --- ------------------------------ --- <br /> ADDITIONAL COMMENTS----------------------------------------- ----------- <br /> _ t <br /> ------------------------- -- ----------------------------"------------------ --------------------------- =------- = <br /> ------------------------- ---=--------------------------------------------------- <br /> ------- ------------------ ---------------------------------------------------------------r-- <br /> -- <br /> - -------------------------- <br /> ---------------c----------------"-------------------...------------------------j----------------------- <br /> " 7 <br /> ----------------------------------------------- '�Final Inspection.b -------------------------Date--------------------------------- ----- ---- --- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M k <br />