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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - ---------- --------- <br /> (Complete in Triplicate <br /> Permit) U,0 _7 <br /> -------------------------------------------------- <br /> ---- Date lssued._7.- __-"..-__ <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 hoWin described. <br /> This application is made in compliance with County O inance No. 549 and exp ing Rules nd Regulations: <br /> JOB ADDRESS/LOCAT N- � _ - r } - CENSUS TRACT <br /> Owner's Name - ----------------I ----------------- -------------- ------------------ Phone---- ` r�—----------- <br /> Address------ <br /> ---- ------Address------ cl s - --- --------------------- -- ------- -------------------------- ----------------City Zip---- .Z U------ <br /> Contractor's Name- ...... �cs�__�ld-"' License #.. cp� ------Phone.-�.. 3�------ <br /> Installation will serve: Residence.e- Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------------- ---------------- <br /> Number of living units:----- --------Number of bedrooms..--.....Garbage Grinder------------Lot Size... ----------------------------- <br /> Water Supply: Public System and name------- --------------------- -----------------------------------------------------------------Private [ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ PEtat'❑i Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material------------Dyes;type-----------------------------_- <br /> [Plot plan, showing size of lot, location of system in relation to wells, building's; etc. must be placed on reverse side.] <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public seket' is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-------------------------�------------------------ ---------Liquid Depth-------------------------1),j <br /> Capacity------ - ---- -Type----------------------Material ------------------------No. Compartments-----------------------------------� <br /> - - - - <br /> Distance to nearest. Well------------------------------- Foundation--------------------------Prop. Line------------------------_-- <br /> LEACHING LINE ( ] No. of Lines---------------------------- Length of each line.----:--------------------- --.Total Length..--------------------------------------- <br /> 'D' Box-------------Type Filter Material----- ---------u? .Depth Filter Material--------------------------------------=------------------- <br /> Distance to nearest: Well------------------- <br /> - /.Foundation----------------------------Property Line----------------------------------- <br /> SEEPAGE PIT [ ] Depth----------------Diameter------------- <br /> -- /Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth.---------------------C- ------------- -- --Rock Size------------------------------------------------ <br /> Distance to nearest: Well.------- ------------------------- ----Foundation------------------ ------.Prop. Line---------------------------. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------ 1-------------------- `-:-- :- --------------------------- ------------------ <br /> '," <br /> Septic Tank (Specify Requirements)--------------------= ------ -----------------------=_ --------- f ------------ <br /> Disposal Field (Specify Requirements)------------- ----- - -A-4v--- - 't`` 1 `�"z�— <br /> U- --- <br /> ------------------------ : ---- ----------------------------------- ---- <br /> ° ---------------------------------- ------------------------- <br /> ------------ - — ----- <br /> -- <br /> (Drowlexisting 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 as <br /> to become suWtoWoman's C pensation laws of California." <br /> Signed------------ :: �T . . --- ---------------------------- Owner <br /> BY ------. Title.- C�'-----`----------- <br /> her than owner) <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -G DATE _-- g�--- -------------------------- <br /> --- ---------- - ------ - ------------------------------------------------ <br /> DIVISION OF LAND NUMBER-------- ----------------- ------- DATE <br /> ADDITIONALCOMMENTS---------------------------- ------------------------------- ----------------------------------- <br /> -------I-- ------------------------- --------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------- ------------------------------------------------------------------------------------ <br /> ------------------------------------------------------- ------- -- --------------------------------------------------------------------------------------------------- <br /> ----------------------- <br /> Final Inspection b ------ ----Date <br /> Ery 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />