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} F ' <br /> FOR OFFICE USE: J ry <br /> -APPLICATION FOR SANITATION PERMIT <br /> ---------------- - FO OFFICE USE <br /> I �3 • - <br /> ----- <br /> ` + "{Complete-in Triplicate) r <br /> r Date"Issued.... <br /> - --------------------- ----------------------------------- This Permit Expires,l'.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 Coun prinance.No. 549 and existing Rules and Regulations: t <br /> JOB ADDRESS/LOC N______________ __ <br /> / _ - <br /> --------------------CENSUS TRACT <br /> Owner's Name- <br /> ........... <br /> Ph <br /> ------ - - --------- k "hf n <br /> - -. <br /> ----------- ------ one---- <br /> Address--- <br /> Y <br /> -- <br /> Address_' 5 �`L� J� G _Y <br /> tY ----- -------- ----ZiP <br /> Contractor'.s,Name__`_8 _"_- -- !S <br /> ; ---------------- <br /> ------ '=d7Cs 6= 1 <br /> rLicense #__ -___.--�-�---Phone._-.- <br /> Installation will serve: Residenceg—Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> ) . - 3 Motel E] Other '-=------ ------------------ ---------------- <br /> Owl <br /> Number of living,'-nits:- Number.of_bedrooms`-3___-_Garbag.e Grinder___----_--_Lot.Size.-- ___ <br /> ----- ------ - ------. ----- <br /> Water Supply: Public System name___ ,__-and _ _ <br /> .. _ i n ---------------------- - .: . ------------ ==-_-------------------------- ---------------------- ---------------Privatex <br /> Character of:soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat[J Sandy Loam ❑ Clay Loam ❑ j <br /> !, ! "�;Hard an <br /> w.. a P . ❑7 Adobe �' Fill Material—- - -...if ye`s, type--------------- ---------------- ! <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: ( (Noi septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT i[ ] SEPTIC TANK I '1 Size------------------ t -------------------------- Liquid d Depthi ----------- <br /> L ---------- <br /> ---- ------------------No. Compartments------- - =------------ ' <br /> Q. Distance to nearest: Well------------------- ------Foundat on------------i -----------.Prop. Line.--------------- <br /> F i <br /> LEACHING LINE [ ) No. of Lines------------------------------Length of each line---------------- <br /> ----------Total Length.------------------- f <br /> c. <br /> ` D';Box----_._--Type Filter Material---------------------Depth Filter Material'_ _---------------.----_ � <br /> ----- ------- -- <br /> yDistance to nearest: Well--- -----------------------Foundation------------------------: <br /> ---Property Line-- -----------:.-- <br /> P _1 <br /> SEEPAGE -PIT ( ] De th--_-________--Diameter--------------------Number-.--_--_--_-----____--_------_ Rock Filled Yes ❑ <br /> ` Water Table Depth ----------------- <br /> ----------------------Rock Size R <br /> Distance'to nearest: Well--------------------------------------__ Foundation--------------------------.Prop. Line----------- ------ <br /> REPAIR/ADDITION (Prev. Sanitation mit#- -------------------------------------------------Date- <br /> Se tic Tank S ecif Requirements __ <br /> P 1 P Y ) - ----- --- - -_ _ ------- <br /> Disposal'Field (Specify Requirements)--------. " <br /> � a <br /> _: <br /> = ---------------- ---- <br /> ------------------- _ <br /> ---- ----- - <br /> (Draw existing dnd required additiono' n reverse side),' <br /> I hereby certify that Phave prepared this.application and that the work will be done in accordance with San .Joaquin County E <br /> Ordinances, State Laws; and Rules and Regulations of the San Joaquin local Health District. Home owner or licensed agents <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 _n <br /> to beco ub'ect to kma 's Compensation laws of California." <br /> Signed- � r <br /> --- -- Owner 1 <br /> By <br /> - <br /> - -------- Title --- -------- <br /> (If other than owner) <br /> r —'FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ DATE.-.- �- <br /> ------- ..------------ -�� ------ <br /> DIVISION OF LAND NUMBER---------- --- ------------------- -----------------------------------.-------------------- --DATE------------- ' <br /> AQDITIONAICOMMENTS ------------------------------------------------------- ---- ---- ------------------------------------------------ <br /> - , <br /> ----------------------------------- --- <br /> - - J <br /> Final Inspection by: - Date -- ---- --" ` C __ -___ <br /> ---- -- ---------------- <br /> - -- ---- ----- <br /> - - = G <br /> EH 13 24 x. SAN JOAQUIN LOC L HEALTH DISTRICT F&s 21677 REV, 7176 3M <br />