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FOR OFFICE USE: FOR OFFICE USE: <br /> 'PLICATION FOR SANITATION PERMIT ewe ��� <br /> (Coplete in Triplicate) f-V <br /> ......... ......_. _._..- :y Permit No. <br /> m <br /> .... __.. . .. ....... . ....... <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 tt Ordinonce No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ........ CENSUS TRACT . <br /> Owner's Name ....... ... ................ . ......_. ... . ......Phone. 0% Sq 'L <br /> Address_.. ......./Ycem /eoch�NCity.-rY'/3.ey...._......... .......Zip. <br /> Contractor's Name _. . >... ru.rh.E?!Y ..'f....... . .... ... .................License #../66"�r'' ....Phone$!$;; <br /> Installation will serve: Residence ❑ Apartment House ❑- Commercial JK Trailer Court ❑ <br /> Motel ❑ Other............................ <br /> Number of living units:_ .. ..Number of bedrooms ...........Garbage Grinder.---. ......Lot Size _. . <br /> Water Supply: Public System and name ..... ......... ..._........ -- -- .. ----........... .... . ...... ..... _...._._. . . ....... ..... Private C l <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................ ........ <br /> (Plot plan, showing size of lot, Ioccltioii'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 ( J Size.:` .._'............ ------.........._...................Liquid Depth - r' <br /> Capacity.IpYS.M4.7......Type.._./.9._ !I!+t )Material...t.......-....4.......No. Compartments_ <br /> Distance to nearest: Well.. ....... ';; .COO ._..............FoundationProp. Line <br /> LEACHING LINE [ ] No. of Lines ... A4F...... .........Length of ea�h liner..,/ Total Length .A-2�1a.0 <br /> 'D' Box............Type Filter Material_. ._'pepth Filter Material..!?�?_a................... . _. <br /> Distance to nearest: Well. '-�......t�"�... oun latibn....' �.�........._ ... Line <br /> �_ . <br /> SEEPAGE PIT [ ] Depth-...............Diameter----------- ....Number..... Rock Filled Yes EJ No 's_ <br /> Water Table Depth...... •---- ........... �. ............ .'........Rock Size.. -----...---- ---- --------- ------- <br /> Distance to nearest: Well ..............c__.._........._..-------Foundation.... ......... ...........Prop. line .. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#......... ................_.......................Date ................. ____ ) <br /> Septic Tank (Specify Requirements) . . . _. ... ... .... ....... ----------,-.............---- . -- -_....._...... -- -- ._.. - _... . _ <br /> ._ . -. <br /> Disposal Field (Specify Requirements)_............... .... . ._.. . .................................. --------- ....... . <br /> 1 _ <br /> (Draw existing and required bddition 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 Count <br /> Ordinances, State Lpws, and Rules and',Regulations of the San JoaquiAlLocal Health District, Home owner or licensed agent <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 a <br /> to become subject to Workman's Compensation laws of California." <br /> Signed...C.'-, o.A�.. . '+�..�`'�'�Y.... __ --... .Owner <br /> By.._ .O . ... .. ...... .... ...... ............Title... . ...... .. .. <br /> Pother than owner) <br /> FOR DEPARTMENT USE NLY <br /> APPLICATION ACCEPTED BY.. ... .. ._ -�:. _.-....- f�`?.^ - <br /> �........ ._...._DATE_ .. <br /> DIVISION OF LAND NUMBER .............. -. -- ----------- - -- --------- -_.........I...... ....__.... . . DATE _._. <br /> ADDITIONAL COMMEN S -._. /�[.cn.u�,. - ---- .. Z� .....e,. <br /> e <br /> ...4�....4,4--o ..A.. . .......� _ <br /> ............ ............c..................- <br /> ... .................... ... . ... . <br /> Final Inspection by;.. <br /> l/2............. . / � �� <br /> P <br /> .................. ...................Date-.. _. .-. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7­_ <br />