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f � <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- ----- --- ---------- --- <br /> (Complete in Triplicate) Permit <br /> ----------------------- ------------------------------ <br /> " Date Issued-��-^S_>> <br /> ------------_--------_-------_----------- --------- -__ This Permit Expires 1 Year From Date Issued <br /> E <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 /> IO _. N1 -------------- <br /> ----------------------JOB ADDRESSILOCAT -CENSUS TRACT <br /> Owner's Name---------- ----- -& - ------------ ---Phone----------------------- <br /> Address �� -w -�v---- = `C� - - - ---------Zi <br /> 9. <br /> Contractor's Name ----------- - -44-6--- --------- '` --------License #-----------------------------Phone--------------------------------- <br /> Installation will serve: Y Residence [T�Apartment House❑ Commercial F_­) Trailer Court ❑ <br /> •: -•-• •� - j '� Motel _ �r_Garba e Grind � I <br /> r ❑ - --- ----------------- <br /> Number of living units:--- of bedrooms=._; g e•r_.__._._.__.Lot,Size___---------_-----_----. ------ _____----.------ <br /> Ill <br /> Water Supply: Public System and name__ - 1-____ .- _ - _;_ __� __.-_, ______,.- Private' <br /> i �l <br /> Character of soil to a depth of 3 feet: Sand ❑ :Silt n Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ [ <br /> h. �.. <br /> Hardpa ❑ Adabe ❑ F Fill Material....--_....__If yes, type_..'.___-_+__�___ ___ <br /> # s <br /> (Plot plan, showing size oflot, 'lo�`cation of system in relation to•wells, bu.ildings,�ete, must be placed on reverse side.) <br /> NEW INSTALLATION: "(No septic tank ;or seepage pit permitted if public seweri a ailable within 200 feet,) <br /> �PACKAGE TREATMENT SEPI[TIC TANK , Size----- ----_-'"---__"-_------------------�-- - -_------:' <br /> ____--Liquid Depth---------------- ----- <br /> (�n <br /> rt <br /> �. . Capacity.-------- <br /> Type-----------------------Material--------------------------Na�sCo <br /> mpartments---- -- <br /> -- ---- <br /> 'Distance.to nearestWeYL-------= � --"--.Foundation ' ... Prop. Line <br /> : --= <br /> NGLINE ` ► <br /> [ ] No. of Lines Length of1Yach-line. ' ��-rvt ___� Total. Length _. . _-- ___ _"-__--_- <br /> D' Box-!-__-- <br /> ---Type Filter Material------------------- Depth Filter:Material--, - ----------------------------------------------- <br /> Distance•to nearest. Well__-_."_-_.-___.• :._ Foundation rcperty Line. --------.----------------------- <br /> SEEPAGE <br /> _______ - -_SEEPAGE PIT [ ] Depth...! ___ -_---Diameter _ __ _ __________Number __: Rock Filled 4 Yes ❑ No <br /> Water Table Depth .. =------ ------ ---Rock Size4------------------------------------------------- <br /> Distance,to nearest: Well --------------------Foundation--------------------------Prop. Lin ------------------------ <br /> REPAIR/ADDITION <br /> ------:----------------REPAIR/ADDITION (Prev. Sanitation Permit#_-.- Date_____________ ______ -__::_.-__-_.-_--_____) <br /> Septic Tank (Specify Requirementls)--- = - __-_L_. -------- - ---- ----- - = -------- ------------- -------------------------- <br /> ¢ f ) --- <br /> Disposal Field (Specify Requirements) ---- -- ------ '- = -" <br /> - ------ � � <br /> '.. ----------------- - <br /> ]Draw existing and required addition on reverse side) <br /> I hereby certify that I have preplared this application and-that the work will be done,in accordance with San Joaquin County $ <br /> Ordinances', State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the followingI... 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 became subject to Workman's .Compensation laws of California." . .. . ,. .... <br /> Signed-' ° = f� `` = Owner <br /> r . ;.. . s.._ . ` - <br /> LpBY' -I :::---- = Title-- �j O►v�QQ.�.N -------------------------------- <br /> -- <br /> r <br /> # (If 'other'than,'owner) _. <br /> FOR DEPARTMENT USE ONLY` <br /> APPLICATION ACCEPTED BY- II� - - .-DATE f :., - <br /> DIVISION OF LAND NUMBER---------------------------- - --- - ----. -----DATE.-- - ------ <br /> ADDITIONALCOMMENTS ---------- --------------------------------------------------------I----- --- ------------------------------------------------ ---- --------- ----------- <br /> --- - .. _ <br /> -----°------------- ---------- --- -- • I� ------ ---- ------------------------------------------- <br /> - ------ -- - -- --------------- --------------------------------------- ----- ------ -------------------- ---- <br /> --------------------------- - - - ------------------------ ---- ----------- <br /> Final Inspection by:------.. � = Date. <br /> EH 13 24 ;i SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV. 7176 3M <br /> it ,�� <br />