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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------- - ----------------- Permit No <br /> -- -------- --- [Complete in Triplicate} - <br /> ------------------ -------------- - Date Issued <br /> This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct andinstall the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 arid,existing Rules and Regulatigns: A <br /> 'L .E-c •�'I'�'� r l ` _..CENSUS TRACT ° <br /> JOB ADQRESS/LOCATION.__ �- - [ - - <br /> Ovvner's Name Phone-------_------- ------------------t <br /> E <br /> _ -- ------- -- <br /> 4 -- ' = r City - ZIP <br /> Address -------------- -------- - .. V, <br /> ~ {rR' �ll_-Iiw �------.- --LicensePhone__. -- - L� - <br /> Contractor s Name____.._ .. _ 1, <br /> Installation will serve: Residence 'Apartment House❑ Commercial❑ Trailer Court ❑ <br /> ,y <br /> i -. .t otel ❑ Other <br /> j { x___ Lot.Size __ <br /> f -------- <br /> Number <br /> of living units:----- _Number.ofbed,roo-ms_.--2�arbagaGrinde <br /> Private <br /> -name-----------`:----- ---------- ------------------ ----- ------ .---=--- --Water Supply: Public System and <br /> : <br /> Character of soil to a depth of 3 feet: ' Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam E] <br /> r Hardpan ❑ 'Adobe Fill Material-- ---------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 INSTALLATION: No septic tank `or�see 'a' :pit permitted if public sewer is available within 200 feet,] ► { i <br /> F j l <br /> -sLiquid Depth-------- ---------- <br /> PAGE TREATMENT a SEPTIC TANK t Size V CAft <br /> ---'-Type.------ ---__.::Material No. Compartments <br /> t =, Foundation '----- --------.Prop. Line - <br /> { Distance to nearest: Well:__._i}-fl�- <br /> n �- ------ <br /> V ,�/� 1-: -- _ _ Length of each line.---- Filter <br /> ---------------.Total'Length _- -- U---- <br /> LEACHING LINE , t7�" . No. of LLines-, � �..t>�-� - . �, ���� - t f ,.Y <br />► , D Box.--�./ _ _ Type Filter Material- _�'�-'_'-�-'.Depth Fit Material-__----B7 --------------------=-- ---------------------- <br /> Distance to nearest: Well-=--.-----------`--------- --.Foundation--- -----------------------Property Line------------'--'------------------- <br /> tuber_ L. -------- Rock Filled 'Yes No ❑ <br /> SEEPAGE PIT ] Depth- -__.Diameter._.. --__-_----Nu <br /> Water Table Depth-' -:- - ------------------------- <br /> Distance <br /> ------------ --- Rock Size__ <br /> f . <br /> Foundation Pro Line <br /> Distance to nearest: Well_`-- -----------------------�,-f---,--- - - p• t. <br /> s --.Date.----------------- ------ -----------=-----� <br /> � REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------------------- - <br /> + V <br /> ' Dis osal Field (SpecifyRe uirements) --------------------- 1•-------------------- ---- ---------''----- ---------------------=----=- ----------- ------------- -----•--------- <br /> Septic <br /> Tank (Specify Requirements)---------------- +------- --- ----=--------- -----= <br /> .ter. - ------------------------- -------- <br /> ----------- <br /> -- ------------------------ <br /> _ <br /> (Draw existing and required addition-on reverse side) ' <br /> I hereby certify that I have pr pcired 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 subject to Workman's Compensation Iawof California." <br /> Signed-- ----------------------- ------------- - ---- ----- ----------- ---,Owner <br /> -Title------ <br /> t /1 <br /> ieN►• - <br /> Of other than owned <br /> 3 ! <br /> { - FOR DEPARTMENT USE ONLY •. <br /> _ DATE 1'-r?~7 <br /> APPLICATION ACCEPTED Y-_- <br /> DIVISION OF LAND NUMBER ----- DATE--- --- ----- - ,--- <br /> ----- --- ---- -- ------- - <br /> ADDITIONAL COMMENTS-- ----- ------�--------_-----���----.- <br /> - <br /> -- ------------------------------- <br /> ------- --- ---------------------------------- ----------=-------------------------- <br /> ----------------- <br /> ---------- --- <br /> -M 12 �' <br /> ...... -- _ ------I-------------- <br /> - ------------- -------------------------------------- <br /> Final Inspection by:.- ` -- - -----------------------1--------------Date----- --F�2-b�� Rev.-------------------------------- <br /> -'EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />