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A <br /> FOR OFFICE USE:� <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------- Permit No. <br /> (Complete in Triplicate} <br /> -- This Permit Expires 1 Year From Date Issued Date Issued _' ___.__ <br /> ,n <br /> Application 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 aniexisting Rules and Regulations. <br /> a <br /> �o <br /> JOB ADDRESS/LOCATION ._�._��l_#'.2_`_ �._�---CQ°IV'��SS--------------Es_CA LAN--=------CENSUS TRACT ------_-.------.----------• <br /> C <br /> 2 4 <br /> Owners Name _ ' " "1..�L�� _� K ne <br /> 0 A <br /> Address ---------..51 _b '; ----------- --------- <br /> city _.E+? L. <br /> Contractor's Name ---------4 VJ N ------------------------ ---.License # --- -:-------------- Phone ------------------------------ <br /> Installation will serve: Residence Apartment House-[] Commercial :❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------- <br /> ==--------------------- ------ <br /> Number of living units:_____ ---of bedroomsGarbage Grinder ___ Lot Size RC_R9G - <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private E <br /> Character of soil to a depth of 3 feet: Sand'J] Silt[D Clay E] Peat❑ Sandy Loam Clay Loom ;❑ <br /> _ -_ <br /> Hardpan2K_ <br /> } �X be•,.'-. ,N;FillMaterialr_-_-._._.=-:1'f_ ei;t__ a ------ - '- <br /> if <br /> (Plot plan, showing size of lot, location of system ,i6.relation to-wells, buildings, etc. must be placed on reverse side.) <br /> NEW-INSTALLATION: {No septic tank or <br /> p seepage pit permiiTed_if_public sewer is available within 200 feet,) x <br /> PACKAGE TREATMENT [ } SEPTIC TANK'[ ] Size___, ____ -f-_------------------------- Liquid Depth <br /> � .- <br /> _____--------- <br /> Capacity <br /> ______ <br /> Ca acitY Type --___________ -Material"'-__ �_____ No. Com <br /> Distance to nearest:. Well '-; - Foundation\�____________________ Prop. Line <br /> LEACHING LINE [ ] No. of Lines/______.__ '_:_:__ -_- Length of each.Brae.______ _-Total-Length- _--_-_____________ <br /> D' Box ---.�_-:_=_ Type 1 filter Materia-I- _ -:_` t--=1?epth iFilter Material ------------------------'---••--------.•---- <br /> Distance to nearest: Well __r--- __!-------------- Foundation ____ ___________________ Property Line _________________------ <br /> SEEPAGE PIT [ ] Depth ---------------------- Diamefer 1:-------------- Nbrkber ----------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth`------------1=! =-----------------' ------Rock Size -------------------------------- u <br /> Distance.to nearest: Well ------I------------------- --''- .._Foundation -------------------- Prop. Line _._----------:---. _ <br /> _— _ ---------------------------------- <br /> 'Septic <br /> ' <br /> REPAIRfADDITION(Prev. Sanitation Permit#�:�_,��, ��------------------ --�.,f._ Date ----�----------------------------1 <br /> .- --- --------- i — --------=-----•--------------- ------------------ ---------- ---- <br /> Septic Tank (Specify Requirements} ________.)u�=.�, 1 f,s- y} ::.. -, r 1 <br /> Des <br /> sal Field (Specify Requirements) ti, -c".T�rJ ------��---- ` Fo�ff -- J:1 AtH <br /> -: 1 �� �� X <br /> Zn-------- -------- <br /> ---------------------------------------------------- <br /> 'A 7�"----------------- ----- <br /> ------ ---------- ------ ------ <br /> ----- ------------------- <br /> ------�...v - --�. --- - F _. r :: <br /> ;a .., -,(.Drau_existing-and required add�fion an reverse ,. 4 <br /> I herebyp certify. that I have prepared this application and that the work will be clone—"h. accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local iHealth District. Homeowner or liven- <br /> sed agents 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 , <br /> as to become subject to Workman's Compensation laws of California." ` <br /> Signed 1�t- ------------------------, -- Owner <br /> Title ........................ <br /> ------------------ ---------------------------- <br /> ---- <br /> BY --= ---- - <br /> (If other than owner) I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY '_ •� _._____ _ ___ --_ -__-_- _. DATE r 4`? <br /> BUILD11�1G PFR7Vf1T-ISSUED:' '..` - ---- T_ -[3AiE _ <br /> ADDITIONAL COMMENTS ------- = = -� Via_ �- <br /> ... ..._Y.�--------� � - -- -- ----- ------- . --- -------- -------- <br /> ------------- --------------------- - ----- ------ ---------- ------- - : -- - --------- <br /> --------------------------------- <br /> ! <br /> -- - -- -- - <br /> ---------------------------- - , <br /> - ------------------------------------------ <br /> - - - ------- -- <br /> ----- ---- --- -- <br /> Final Inspec <br /> -- -- ---------------------------------------------------Date - - - ------ ----- <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />