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FOR OFFICE USE: FOR OFFICE USE <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------- --------------------- <br /> '�� [Complete in Triplicate] Permit No..7�-� <br /> . t.' �yam. t �," <br /> _ - *<t <br /> ------------------ -- ------------ -------------- - ' . e".� I <br /> �: � r,;,�,,,,, v ,," "� Date lssued..�'r/4-.�$� <br /> ------------ --- __ :---;_-------_-:__. __...___--- This Permit Expires"1 Year From Date Issued <br /> " <br /> r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This pplication is made in compliance with County Ordinanc,%No. 549 and existing <br /> Rules and Regulations: <br /> JOB ADDRESS/LOCATION,, __ __.,;: , CENSUS TRACT._.. <br /> = <br /> TRACT. .._:.- J-c-------- -- <br /> �D <br /> Owner's Name - -- ---------- ----------------------- ---- ---�----- <br /> . <br /> ---- ------- - --- --- Phone---� : <br /> Address - ---------- -' ---- <br /> F Ci --Zip---- <br /> Contractor's Name--- �." ------ '-- -.--- -------= -License #_0�.7 "ar f Phone 'C <br /> Installation will serve: Residence($' Apartment House ❑,' Commercial ❑ Trailer Court' ❑ <br /> Motel ❑ Other---------- - :-- 1 --- <br /> Number.of living units:-- __/-__--_-Number,of bedrooms___'-Garbage Grin der...;_W.=....Lot..Size._: -. __ __.- "".- ._-..---.�__ <br /> Water Supply: Public System and name - = `--------- ---.1 --- ------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand Silt El ',Clay ❑ Peat❑ - Sondyl;orn 0 Clay Loam F] t <br /> ._ . <br /> Hard pari ❑-� AdoKe ❑ " Fill Material-..--1"_ --If yes;type------------------------------- <br /> (Plot plan, showing size of lot,llocation 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,) 4 .� <br /> PACKAGE TREATMENT [ ] : SEPTIC TANK•: '[�]. Size------------ --------------------------------- ,-->Liquid Depth.:------------------------- <br /> Capacity--------- <br /> - ------'---- <br /> Capacty-.-----" Type '' = Material,=- --- -----="'`No. Compartments f <br /> Distance to nearest: Well--- ___ ` =—Foundation-_------------------------Prop. Line---------------------------- <br /> LEACHING LINE [�] No. of Lines.-- ----------- „_.__,.Length of each line ,Total Length ------- <br /> D' Boxes-------.;Type Filter Material-- .-----.Depth Filter Material._--- --------------- ----------------- ----- <br /> Distance to nearest: We ------ ---------------------Foundation- -------------------------.Property Line----------------- ------- + <br /> SEEPAGE PIT '[ ] Depth._--------------Diameter--------. <br /> a � Number ---------------------------- sRock Filled Yes No ❑ <br /> Water Table Depth ----- - -----=------------- ----- ---Rock -Size------------- - # ------------------- <br /> --------- i <br /> t # <br /> Distance to nearest: Well--.---.--'--------------------------- ------Foundation--_------:-----W_"-_-._..Prop. Line_---------------- <br /> i <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------- --- `-----= -----:Date----------------------------------------------- <br /> Septic Tank (Specify'Requirements)---= '� .._ - ------- = -------------------------- <br /> 4 <br /> _ <br /> Disposal Field(Specify.Requirements]... _.-___- <br /> = - ; <br /> ` --- -------------- <br /> --------------------------------------------- <br /> ----- <br /> - -- ------`------=------=------ --- -------- ------ --- ----------------------------- <br /> = <br /> (Wow existing and required addition on-reverse side] <br /> I hereby certify that'l 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 /> t <br /> '9 certify that in the performance-oflthe work for which this permit is issued, I shall-not employ any person in .such rnanner-as <br /> to becom l to W a an s-!Com ensation lows of .California. <br /> Signed .. ' r : Owner <br /> t , + <br /> BY------------------------ f - -------Title / = <br /> (If other than owner) <br /> e F R E PARTMfiRT USE ONLY <br /> APPLICATION ACCEPTED-BY----------- . _ 4_eDATE.` ---'-g. <br /> DIVISION OF LAND NUMBER ---- ----- DATE. <br /> ADDITIONALCOMMENTS---------- ------ - ---------------------=----------------------------- ------ ----------------- --------------- ------------------------- ------ <br /> -- --- --- ------------_--- -------------------- <br /> ----------------- <br /> ------------ --------------------- ----------------------------------- ------------------------------ --- ---------------------------------------------"---------------------------- - <br /> ------- ----- -- - -- ? -- <br /> b .{.----. - .- - <br /> Final Inspection EH 13 24 SAN J QUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7176 3M <br />