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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> ------------------------------------------- --- --- -- Permit No.• =1u 3 <br /> (Com fete"in Triplicate) � " <br /> Date Issued_. -3__ <br /> --------------------------------------------------- ---- This Permit Expires 1 Year From Date Issued <br /> l <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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION : _`T 9�� � L /r CENSUS TRACT--------------------------- <br /> JOB <br /> f� _ <br /> Owners Name------ - ... -- --- -----------f °n --------- ---- <br /> '— "�-'�"F -. e' � h <br /> Address----- Ad Ci --- -------- ziP_ <br /> . � •.,,: Y r � _��+-1' - -------- -�Z�Z 'Phone.-_ --L-` <br /> Contractor's Name- �`^/ g License #-------.--- <br /> <,. c JSP--.-- - _.-_---___ __________________________ <br /> Installation will serve: Residence [► rApartment House.❑ Commercial ❑ Trailer Court ❑ <br /> . . * .,..r. . : . Motel ❑ Other------------ <br /> --------------------------------- <br /> Number <br /> = ------- ------Number of living units:- --1 Number of bedrooms Garbage Grinder---- _ -Lot Size ------------. .- ---------------1--_ <br /> GarbaF <br /> Water Supply: Public System and name - --- ----- ---- ------------ ----- PrivateiL .� <br /> Character of soil to a depth of 3 feet: Sand ❑ 4 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan [ : Ad-abe❑ fi,�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.) 43 <br /> NEW INSTALLATION: -{No. septic tank or seepage pit permittedlf public sewer i available within 200 feet,) <br /> PACKAGE TREATMENT'',[ 'p i SEPT�CTApNK -(�J �� -i Size__}�Ialx� �_�---No. Com artguid mentDepth-- �___ _________________` t <br /> r p <br /> + Capacity v*O- ---.-----Type- ' <br /> - , ype �- p � <br /> f <br /> s t Distanee:t� - W � �--------��a --._Foundation---------!-�'----_-- p- - <br /> _. Pro Line___ <br /> �. nearest: Well : - -------- --------- -- <br /> LEACHING LINE [� No. of Lines-------- -.Length of each line G -----------Total Length.:--..1a�.- '--- --- <br /> + <br /> --�-� 5 /�____De Depth Filter Material---------1�_ ----- i <br /> - Type Filter Mate'rial:- p --------------------- -- <br /> Vbistance•to nearest: Well_`-----552-If----------Foundation------- ---__:___.Property Line-------4--- ----- ------ <br /> Rock <br /> x De Number -? - <br /> ...3 � n t , Rock Filled Yes No ❑�l <br />' SEEPAGE PIT [ pth--. Qiameter-----�-. - -_ _ ' <br /> f .Water Table Depth----- - '. = Rock Size p� x 3 =------ - �a <br /> _` �'to nearest:We]I_'. ___. _U___. -------------Foundation �.'q-�.:-.Prop. Line--- "` �+ <br /> 4 Distance ! ---- -- <br /> REPAIR/ADDITION (Preva Sanitation Permit#------------------------------ --- --=--- -- = Date-----=------------------- ------------- 1. <br /> Eye' I m - <br /> Septic Tank (Specify.''Requirements)--------- -_: -=------=------------------- ----------------------------------------------------- -=----- -- <br /> Disposal Field (Specify Requirements)-- ,.,-.- - ------------------------------------------------------------------=:---------------------------------------------- ------ ----- <br /> -------------------------------- <br /> - <br /> ---- ------- ------- ---- ------------------------------------------------------- ------- ------- _ -----------------,-------------- <br /> ----------------------- <br /> ------------ <br /> ---- ----- - ------- <br /> ----------------------F-- ----- --------------------- - - ----=-------------------------------- ---------------------- ------ - - -------------------- -=------ ---------- <br /> [ -- r <br /> i (Draw existing and required addition on reverse side) F <br /> I 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 1 <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 Compensdtion laws.of .California." . <br /> Signed = ---- - ----=------ --- -. -------..-----=Owner , <br /> B 4r------ ----------- ----- Title `t'�' <br /> - (If.other than owner) Y <br /> FOR'DEPARTMENT USE ONLY" <br /> APPLICATION ACCEPTED. . � ----- Q-y ` 3��f -----------------------=------`--------- --:----- ---DATE.---- " f <br /> DIVISIONOF. LAND NUMBER-------- --- --- ------------------ ---- ---------------------------------------DATE ---------------------------------.--- ----------------- <br /> ADDITIONAL <br /> ----- ---- <br /> ADDITIONALCOMMENTS--- -------------- ----------------------------------------------------- -•-----------------------------I--------------- -------------------------- <br /> ------ ------------- ------------------------ ---------------------------------- ---- ----------------------------------------------------- ------- ------------------- ---- <br /> T € - ------------------------------------------------ ---------•---------------=-----'------ <br /> ---------------------------------------- --------- ---------------------- <br /> Final <br /> --- --Final Inspection by Qate &s sia»Rev. ���6 sM .,I <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br />