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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �� � �� <br /> ------------------- ............................... Permit No. .. / �. <br /> .--.----.. � (Complete in Triplicate) ------�----"- •� <br /> _---------------------------------- ---- ----- CC 99 <br /> ........................... -_...... ` This Permit Expires I Year From Date Issued Date Issued..?. ".:!.-'7 <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and.install the work herein described, i <br /> This application is mgde in_corep.1.ionce�w•i.th-C.ou.nty,Orclinance_No._54'and existin.g_Rules and-Regulations: , <br /> sL. <br /> JOB ADDRESS/LOCATION. /042-0-...../ .s....W.X CENSUS TRACT- ..:.. I <br /> Owner's Name.--- .*Jo66 . .5/sl......--- --- - ..Phone ---------------- <br /> aQ 1Cil <br /> �g..... zip Address.... / �f - <br /> Contractor's y rI, <br /> Name_ e `lt - .----(.,61 5 �.-- - - --- ---- -------License U-/......Phone_ <br /> Installation will, serve; ' Residence} Apartment House.[, Commercial E] Trailer Court E] <br /> Motel ❑ Other. ----..---- ------------------------- <br /> Number,of!living units_/.,.-...-Num'b_er of bedrooms- aGarbage Grin_-,-�l�d-Lot Size_'A=) -- -------.:_........_...._-.. .. <br /> Water S ply: Public System and;name...--- ... =I ------------------------------- <br /> Private <br /> Character of soil to a depthfof 3 felt: Sand_❑' Silt ❑ Clay ❑ Peat ❑ . Sandy Loam Clay Loam ❑ <br /> Hardpan ❑- Adobe ❑'`"F"ill Material �' °lf yes type-.-.--" - ---------------------- , <br /> {Plot plan, s_howin'g size of lot, location of system=in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTAL-LATIONc .(Na septic tank or-s`e page pit permitted if public sewer is available within 200 feet,) <br /> .PAGKAGE TREATMENT [ ] SEPTIC TANK -- --------Liquid Depth...: ..-..___........... - <br /> I l Size............ �. <br /> Caap�p""acity _._—Type...- ......--..-Material----------------------,...No. Compartments------------------------------ <br /> bistanee to nearest:Well-------• ----- Foundation - Prop. Line <br /> -LEACHING LINE ] No. of Lines..............................Length of each line-------------------------------Total Length ......... ...... <br /> 'D' Box..I.........Type Filter Material.. - Depth Filter Material- ------- ------------ ----------------- ----- --------- <br /> • f <br /> sem' <br /> Distance sto nearest•Well-:.-----i--- ------ - ---- Foundation--------------------------.-Property Line.....-..--------------..------., <br /> A <br /> E PIT [ ] Depth)..............Di.a'er-------- ----------Number----...-------.-------.---..---- Rock Filled Yes ❑ No <br /> Water,Table Dep;h.--------------------------------------------------------Rock Size---------......-------_---- ------ <br /> ADistar►ce to nearest: Well-------.-`----- ---------------------------Foundation_...........--------....Prop. Line--------------------- <br /> REPAIR/ADDITION-'(Prev, Sanitation Per.- t#. 1 ...--------.Date.........- fi <br /> Septic Tank.SpecifyRequirements)..... C ------ r..�..... . ] <br /> l <br /> Disposal Field (Spee y Requirements)'._-----_ter-�-------.-------------------------- <br /> ------ Gc1i .:k. .. / ...f J 5 ... .....................:.....�� ----•------------ <br /> I ' � r y <br /> / 1L '`SLE'. �------ ----- - �.. <br /> ..-----&a7` ._-.:.. p f� ----------------•----------- - ------. --- . ----------- ------- <br /> (Draw existing and required addition on reverse side) <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 taws; and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: i <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 orkman's Compensation laws of California." <br /> Signed------ ------..- ..... . . ...... --Owner ) <br /> By.........'.. .----....... Title <br /> (If othe owne , <br /> OR EPART ENT UsFpNLY <br /> �-- - ----....._ -DATE.. ---.... <br /> APPLICATION ACCEPTED BY------------- � ... ....- .-_ - <br /> DIVISION OF LAND NUMBER.... '..... -..-.. . ---•----------------- DATE <br /> ADDITIONAL COMMENTS-- ------- ------- k --- - --------------------- <br /> ----------- ----------------•-------------------------------------- ------------------- <br /> .------------- <br /> .....- ----- <br /> i f <br /> Date 1. .......... ..... <br /> Final-Inspection bY <br /> Fas zi6ry Rev. 7l76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />