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FOR OFFICE USE: fv FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------- <br /> (Complete in Triplicate) Permit <br /> Date issued- <br /> -------------------------------------------------- ------ This Permit Expires 1 Year From Date Issued <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----------. 7-------- ------- -------------CENSUS TRACT------------------------------- <br /> Owner's Name- f(_�-GV.Ig. --------------------- ---- ------------------------------- ---------------------------Phonea_� <br /> . - t <br /> Address. ` � <br /> �- P- ---------------Z1 --- <br /> � � �Q <br /> Contractor's Name. F �� / - ----- ----- -- -------------License A 6 ---Phon + - ----- - ----0- <br /> Installation will serve: Residence Apartment House[] Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-.- ---------------------- }-* <br /> Number of living units:__._.'�.__._____Number of bedrooms----Garbage Grinder------!-----Lot�Size__----41--------- ---------------------------------- <br /> Water <br /> __ 41_______________________________________________- <br /> Water Supply: Public System and name-------------- -- -------------------- ---------------------- ---------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam [% Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material------------If yes, type 1 <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 seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK- {-] ,p Size.__---- jv�___________________Liquid Depth______ <br /> Capacity.. TYP /"� aterial '_ -- No. Coartments-------02----------------------- <br /> Distance to:nearest: Well-------- Fo _!_f_= <br /> undation .p___-__------------- Line______ ----------- <br /> LEACHING LINE [ ] No. of Lines----- -------------------Length of each line.__ ------- Length-------z;;V.6C6 <br /> Type Filter Materith Filter MateriaooeZ---------------------------- ----- <br /> 'D' Box__ _ _______ <br /> t �"p ---- Foundation--------i- -----------Property Line----- �---------------- <br /> Distance to nearest: WeIL_._l__ _________ �# <br /> E PIT [ ] Depth__,_/.q.......Diameter— ._Y:7__.____Number--------- __` Rock Filled Yes, — No ` , <br /> F1� CY Water Table Depth._..-----------------------------------------------------Rock:Size-'-- -------------------------------------------- <br /> Distance <br /> ------------------- -----------------------Distance to nearest: Well-------------------------------------------Foundation,_.___________.______-._.Prop:.Line.-------------------------- 4 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#___________________________________-------------.Date-- __ _) <br /> SepticTank (Specify Requirements)--- ------------------------------------------------ -------------- ----- s --------------------------- --------------------------------- <br /> Disposal Field (Specify Requirements)------------ - --- ------------------------------------------------ -- ----------------------------- <br /> ------------------------------ <br /> t <br /> ----------------------------- ----------------- -- ----------------------------------------------- ------------------------------- ------------------------------ -----------------------=----------- <br /> r '' n _ t <br /> -------------- ---- ------- ----------------------------------------------- <br /> ----------------------------- _a.N\_ t-� <br /> ------------------------- <br /> i (Draw existing and required addition-on reverse side) <br /> I hereby certify that I have prepared this application and that the worlr"Will-be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and' Rules+arid .Regulations of the San Joaquin;L_ocal.-Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certifythat in the ! , - s <br /> performance of the work for which this permit is issued, I shatl not employ any person in such manner as <br /> to become subject to )Nork1pan's­Compensati%m laws of California.`" <br /> Signed--------, ------ --------------------------------Owner <br /> BY---------------------------- -F----------------------------I------- --------------------Title.--- <br /> ---------------------------------------- <br /> (If otheT-than"(5wner) <br /> FO <br /> DEPARTMENT USEVONLY`' :;: <br /> APPLICATION ACCEPTED BY------ -------- - ----- ---- --------- ------------------------------------------------DATE..--- -- --��.�C------------------ <br /> DIVISION OF LAND NUMBER____________________ _ � <br /> ------------------------------- <br /> --------------------------- <br /> - -----------------------------------------------------{ <br /> DATE------------------------------------------------ <br /> ADDITIONAL <br /> ------------- --- -----------------------------ADDITIONAL COMMENTS--------- --------------- <br /> - .} - <br /> ----------------------------------------------".,SAN <br /> ---------------------------------------------------------------------------------------------- - --- - ---------- <br /> Final inspection by:-------------- ------------------------- "----- -------- -- -------------------------- ---- <br /> -- ---Date '� ------------ <br /> EH 13 Y4 JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />