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a <br /> ' FOR OFFICE USE:, APPLICATION FOR SANITATION PERMIT <br /> � w '� <br /> --------------------------- ----------- ---------- <br /> (Complete in Triplicate) Permit No <br /> ---------------------- ------------------------------1 This Permit Expires 1 Year From Date Issued <br /> Date Issued s- ----------- <br /> Application <br /> : dApplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described, This application is made in compliance with County Ordinance-No:549 .and-existing..Rules..and Regulations. <br /> JOB ADDRESS/'LOCATIONc2 Z-3 ---- ---: I_"`__l�Kt _.:-----y'.-CENSUS .TRACT;---�1-r-_- ------ <br /> Owner's ame ---- ------- �--------•-•--------------=---------------------------------------1--Phone = '--------------------------- <br /> Address3_ .__-- __-_ ---- <br /> /�7 J�1-*&, City �1( f ' <br /> Contractor's Name ._ ✓-� - -_ - �� �_ R237-07"_ <br /> License # O Phone <br /> Installation will serve: Residence Apartment House�❑ Commercial :❑Trailer Court i❑ <br /> I. <br /> Motel-0 Other -------------------------------------------- �/J <br /> Number of living units:------ ___ Number of bedrooms _____Garbage Grinder 4N!a... Lot Size --/ �`��t",r� _- --------- <br /> Water Supply. Public System and name ----------------------- <br /> ---------------------------?­_________ 'Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt"El'-% Clay .❑ Peat❑ Sandy LoamCla`,`-;Lo m : - -•( <br /> Hardpan ❑ Adobe ❑ Fill Material _.N.0__ If yes, type ---------------------______ <br /> (Plot plan, showing size of lot, location of system in relation to wells,.buildings, etc. must be placed, on reverse side.) <br /> NEW INSTILLATION: (No septic tank or seeps bit permitted if public ewer is available within 200 feet,) <br /> PACKAGE fREATNIENTSEPTIC TANK, Size__ ___ <br /> f � �--- Y��l�--------------- Liquid <br /> . _ Depth ------------- <br /> Capacity, TYpe � ateria �No. Com � <br /> er <br /> istance io--nearest: Well ---- __f-- ------------------Foundation 1__6--------------- Prop. Line _---:-------- <br /> LEACHING LINE No. of Lines ---- Length of each line_____ _------------- Total Length _;f_�d______________ <br /> f 2� ------- ---------------------------- <br /> ------------- <br /> 4 <br /> 'D' Box __________ Type Filter Material ______Depth Filter Material"`" <br /> ~--v—DistanFe,to nearest: Well -- -- - -- <br /> Fourication ----- Property"L'ine �----------------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -----'_______-- Number ---------------------------- Rock Filled es ❑ No .0 <br /> t Water Table Depth --------------------/----- -------Rock Size -------------------------------- <br /> Distance <br /> ---------__Distance to nearest: Well ______ ------------------------------Foundation -----.---------.---- Prop-Line _______________..___.- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# - __ ___ ______________________.___ Date ----------------------------------). :_T- l <br /> Septic Tank (Specify Requirements) ` ----------------- ---- --_ ----'.----------------------------- <br /> Disposal <br /> ----------------------------Dis osal Field (Specify Requirements ~ - —-------- ------ - ----- r ----_-- --�--------------- <br /> --------------------------------------------------------------- --------------------------------------------------- F_ ------------------_ _ _ ___ __ _ _------------------------- <br /> --A <br /> _________________._-____ <br /> --------------------------------------- -------- --------- <br /> 4 <br /> (Draw existing and required addition bri rEverie'side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San 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's <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 <br /> as to become subject'to Workman' Compensation laws iof California." <br /> Signed -- ----- - - ----- ------- ---- ---- -----,-- ---------- <br /> Owner <br /> BY ----------- - �� Title <br /> (If other than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ t_R-=------------------------------------------- -------------------------. DATE ____� <br /> BUILDING-.PERMIT ISSUED__._.__=.=. - --- <br /> DATE -----. �--_.--`�--__ <br /> ADDITIONAL COMMENTS ---------------------------------------------------------------------=--------------------------- <br /> ------------------ ------ ---- -'--------- ---- -- - --- <br /> - -- ----- <br /> - ---- -- ---- -- - -- ------ <br /> ------------ -•----------- <br /> - ------ - --' - aw, <br /> ----- - ---- - - -��w_. _ — . - <br /> ------------- ------- - -- ...---------------------------------------------------- <br /> Final <br /> ---.-----.-- ------- ------------------------�-- <br /> Final Inspec -------.Date ------- ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IE. H. 9 1-'6$ Rev. 5M <br />