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FOR OFFICE USE; _ F <br /> APPLICATION FOR`SANITATION PERMIT _ <br /> (Complete in Triplicate) Permit No. <br /> ------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued <br /> Applicationis.hereby made to the San Joaquin Local Health District for a permit-to-construct and�instdll�the work herein <br /> described,This,application is made in compliance with County Ordinances No. 549 and existing Rules and Regulations. <br /> t; � <br /> JOB ADDRESS/LOCATION 4_ _S:M_�- _ G�' "yJ - ------ --CEN S pCT - •= -Owner's Name `" ------ ---- /�� Phone ¢_ ' QT7 <br /> ,� p ---------- -------- - -- - - ! <br /> Address �'. <br /> -- ------------ --- - ---� --��-&��----- -- - , ';�tl - ---. City - - -- -- <br /> ' ------------------------�c <br /> Name " t`"�-'___ . -- ----- ---- --------License # -------- <br /> ---- ---:-----°----_ Phone �f---- <br /> Installation will serve: Residence ❑Apartrrient House❑,Commercial :❑Tr ilei Court ;❑ <br /> Mofel ❑Other( ------�- i-_ t +�0-G + <br /> Number of living units:_._- Number,�of bedroomsw--=-__-=-Garbage Grinder _-'___r.__ Lot Size -.:__ <br /> Water Supply: Public System and name --.-_-_-- __------_ _ $' <br /> •' a,-----------------------------------------------------Private <br /> Character of soil to a de_pth,of 3 feet: Sand )] Silt❑ Clby-E] Peat❑ Sandy Loam Clay-Loam :❑ <br /> Hardpan ❑ ------------ If Yes,type --------------------- <br /> (Plot plan, showing size of lot, fo—ccation of-sysfem in relation to-wells 'buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: {Noaeptic tank or seepage pit permitted) if public sewer is available within 200 feet,) <br /> PACKAGE .TREATMENT'' $` <br /> TREATMENT-![.] . SEPTIC TANK'[ Size LiquidDepth ---- ----------- <br /> ''^�.,:Capacity ---- -- ------------ Type -------------_ -- Material------ --------- No. Come artments a <br /> Aww _-4pDistance to nearest: Well Foundation ---------------------- Prop. Line -__--- <br /> LEACHING LINE __- > <br /> [ ] No. of Lines ------------------------ Length of:ea-ch line___---_______--____- -- Tota! Length ------•____-- _•;_-'- 5 <br /> 'D' Box ------------ Type Filter Material ---n----------------Depth Filter Material _----_---____-----"________________________ i <br /> Distance to nearest: Well ----------------- F 00 <br /> ' ridation --- -------------------- Property Line _____________ <br /> SEEPAGE PIT [ ] Depth ------ ------------- Diameter ---------------- Number ----------------------- Rock Filled Yes ❑ ' No i❑ <br /> Water Table Depth --------------------------------------- --------Rock Size -------------------------- . <br /> Distance to nearest: Wel! ----------------------------------------Foundation --------------- ---- Prop. Line -----------------•---- <br /> REPAIR/ADDITION(Prev. Sanitation PermitSep <br /> istic Tank pelfecfRequire <br /> Posal FieldISP Y qui em <br /> Dents) ---- --- <br /> t <br /> M. <br /> (Draw existing and requiredaddition on reverse side) <br /> Vt <br /> I hereby-certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: �` ; <br /> "I certify that in the performance of the work-for-which-this-perrnit�is,issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." i <br /> Signed ---- ------ ------------------ ----- -- --.>------------------ `-��------------- Owner <br /> BY ------ - ----- = -----------------y S <br /> Ti <br /> tle <br /> -----------(If ---- -- --------------------------- <br /> --------------------- <br /> other th ned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.-•_-__- 1 _ - -- -----•_-, _-- <br /> t •-� -- -_""--=---------------- -•-------------- ------. DATE ---- <br /> BUILDING PERMIT ISSUED .----------t------------------------------ - --DATE <br /> ADDITIONAL COMMENTS <br /> --------------------------------------- ------ -- --------- <br /> ------------------------ ------ ----- - -------------------- <br /> ------------- - — - <br /> -- _ - <br /> Finallnspe��n-b. y Date (Q - -------- <br /> SAN JOAQUIN LOCAL HEkTHr DISTRICT <br /> E. W 9 1-'6$ Rev. 5M ` <br />