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i� <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------------ i <br /> (Complete in Triplicate) Permit No----------------- ----- <br /> -------------------------------------------------------- Date issued- <br /> ­C--------------- _--- This Permit Expires 1 Year From Date Issued <br /> A lication is hereby made to the San Joaquin Loca Healfli-'Gi-Wict for a permit to construct and install the work herein described. <br /> Th9application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> F r - ----------- -------CENSUS TRACT--------------- -- --------- <br /> Regulations- <br /> JOB ADDRE5S/LOCATION------------ -- - -- ---!- <br /> Owner's Name--------- ---------- ---- --- -- ------- ( --- ---- ----- ---------------I-----------------------------Phone--------------- ---------------------- <br /> Address------------------------------------------------------------- -------------------r - - -------- --- ----City---- -----------------------------------------Zip-------- ------- <br /> Contractor') Name----------------------------------------------- �----------------------License # -------- - --- -------- Phone.--------------------------------- <br /> Instal lationliwill serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ OtFEier-f- ------------------------------------------- <br /> Number of I.Ming units-----------------Number of bedrooms_._____I____Irbage Grinder.--_.--_--_Lot Size----------------------------.-------------.---------- <br /> i <br /> Water Suppl`y/�Public System <br /> d�and name------------------------------- ------ ------------------------- ---------------------------------------- Private ❑ <br /> 6 N \ 4 �F <br /> ChSracter o oil to arc ept�of��feef''N5and ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> _c dpa ❑ Adobe ❑ Fill M4erio ....-------.If yes, type-------------------------------- <br /> s plan, showing ize ofyb �ocation 'af`sy5xem in rel to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSL <br /> LLATIO '(i�l ��sep is tar�ktoseepage pit ermitted if public sewer is available within 200 feet,) <br /> PACKAGREATME ] SEITIC TANK [ ] Size----------- -------------------------------------Liquid Depth--------------------------- <br /> --------------------- <br /> EaPa --------------------Type--------------------- .Material -------------------------No. Compartments.-- --- --- ------- --------------- <br /> Distance to nearest: Well---------------#-------- ------------------Foundation--------------------------Prop. Line.--------------------------. <br /> LEACHINNE [ ] No. of Lines-----------------------------Length of each line-----------------------------.Total Length---------------------------------------- <br /> u ti — <br /> <: D' Box--_-.-.--_---Type Filler Material ------ -_-----..Depth Filter Material-------------------------- <br /> Distance to nearest: Well--------------- ------- ----Foundation--------------------.-------Property Line___- <br /> SEEPAGE PIT [ ] Dep th----------------Diameter.-------------------N. mber-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ' -------------------------Rack Size. <br /> ------ --------------- <br /> Dista�torTartist: Well---------------Ly_ - ---Foundation------------------------- Prop. Line -------------------------- <br /> h <br /> REPAIR/ADDITION (Prev. Sanitation Permit'#_____-------------------- ---------------------Date__-__----------------------------------------- <br /> ) <br /> i <br /> SepticTank (Specify Requirements)---------------- ------ -- - --------- Z- ----------------------------------------------------------------------------------------------------------- <br /> U <br /> Disposal Field (Specify Requirements)---------------------- --- ------ ------------------------------------------------------------------------------- . <br /> -----------•-------------------------------------------------�----- ------------------- �t - -------- --------- ------------------------------------------------- ---------------------- <br /> . - t� <br /> -------------------------------------------------------------- ------ ----------------------- --� ----------------------------------------- -------------------- ----------------------- ---- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that._I have prepared this application andit6tIthe work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws and Rules and Regulations of 1Fthe San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the foll�wing: <br /> r�, , <br /> "I certify that in the performance of the work-for.which this ermit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compen atioc) `laws-of-CaTifornia." <br /> Signed -------Ovyner <br /> By---------------------------------------------------------------------------------------------------------Title --------- <br /> (If other than owner) <br /> \F�JR DEPARTMENT US,E-,ONLY, <br /> APPLICATION ACCEPTED BY------------------------ --------------- V` ' = DATE - <br /> NJ <br /> DIVISION OF LAND NUMBER-------------------------------------------- ------------------------ ------ -------------------------- �,DAg---------- --- ----------------------- <br /> ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------- ------v-------------------------- ---` . <br /> ------------------------------------------------------- -------------------------------- - <br /> Final Inspection by-----------------= ------------------------------Date------------- ---------- ------ <br /> EH 13 24 y W SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21427 REV. 7176 3M <br />