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I <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �� �ooh <br /> --------- -----•- ----•------ - -- Permit No.... <br /> {Complete In Triplicate) '"'---� <br /> ----------------------------- / f- 7< <br /> Date Issued_... "-•.---_ <br /> ............................... ---------------- �. -This Pehnit 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 complianc with Codnty Ordinance No.549 and existing Rules and Regulations: <br /> JOS ADDRESS/LOCATION <br /> ............CENSUS TRACT.-........... .._._ <br /> Owner's Nome-.. --- - •---• ................•-........ _._.. Phone...................................... <br /> Address--- <br /> -p_�4....- . .. -•--------- ---- -- - - ------ <br /> . `_ ...... `.._. Zip................ <br /> Contractor's Name__-- -- - --' F.�C----------------•R•'�...... <br /> # ?�+ �- _.Phone._yi� <br /> �f =' /_ r <br /> Installation will serve: Residence p Apartment Hou Coo erciol ❑ Trailer Court ❑ <br /> t r I Motel ❑ Other _.'� ---------.... , <br /> Number of living units;­/......:'Number of bedrooms------------Garbage Grinder------------Lot Size.5;..5D...................... ..................... <br /> At' y <br /> WaterSupply: Public System and name-----1.............................................................................................................-..... ........Priva e <br /> Character of soil to d�depth of 3 feet: rSand ❑ Silt[ICloy[IPeat ElSandy Loam ❑ Clay Loam ❑ <br /> : {"Hardpan ❑ Adobe Fill Material............If yes,type..................... ........ <br /> On <br /> (Plot plaln,=showingsize of lot, location-bf system in relation to wells, buildings,etc.must be placed on reverse side.) 4 <br /> NEW INSTALLArlO l: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size . ....... ... Liquid Depth.-'� ................. <br /> ." Copocity� ___..Type- . P4- Material 4 U......__._No. Compartments__._____..__. <br /> Distance to neareit: Well- Z21-4-•---------- ----------Found tion_. ._. ..._._____...Prop. Line.-6... <br /> x'.< + <br /> LEASHING LINE No. of Lines...._....!...................Length of each line.-�r�! oral Length..��.. , �___� <br /> d D' BOX-.........Type Filter Material.>Sr_/.� __ epth Filter Material_____ . ._ _.------------------- -Distance to nearest: Wel l./-46=0-/..........Foundation.____26--__v---------.Property Line-JAS___ ---------------------- <br /> SEEPAGE PIT [ ] Depth-.............Di a ameter..__................Number................................ Rack Filled Yes❑ Non <br /> WaterTable Depth.........................................................Rock Size................................................ <br /> Distance to nearest: Well.---.......................................Foundation.__-__........_----__.....Prop. Line--.---.---.--- <br /> REPAIR/ADDITION (Prev.-Sanitation Permit#.........................--------------------------Dote--------------------........................... <br /> ) <br /> SepticTank (Specify Requirements)----------- I------------------- ......................................................-.................................-•-•.................. <br /> DisposalField ISpecify Requirements)...................... ...............------••••--------------•-----•-----.........------••---------------•----............_......----..........-----• <br /> .........................................•..... ...------.. <br /> ...... . .......----. ---------------------:!"� <br /> ----------- - ----------....................................................... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work,wilt be'done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Horne owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this pernfit.is�Issued, I shall not employ any person in such manner as <br /> to become lec to k on's ornpensation laws of Colifarnla." <br /> Signed - .. <br /> ------ ------ - - - ------ -� ------------.......----- -----. Owner <br /> By................... : �, ...._.....Title...L`°-�-l,........................._.. <br /> 1f other th n own. t t 'Y- <br />` FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B :_.: ..... f r-----------''='r. . .. ......................DATE,....: ------------------- <br /> DIVISIONOF LAND NUMBER..........................------ ------------------------------------------------------ -------------------DATE----••------ ----------.------------------------ <br /> ADDITIONALCOMMENTS............................................•----------•---•-•--------._.......�- '-------•--••---..-------------------------------------------........................ <br /> e <br /> w..�7r7�n� -. ........... .......... <br /> ---------------- ..............................................................%•-------------------.....--.----------------------------- ------- •-----••--•-•---------------------------------- <br /> .__ ._._..._-----••-------........-----------•-.---••--•••------------.....__ ..._. ... <br /> FinalInspection by:..... -----------------------------------------------Do _. __ ..`.- ....... ..• ------•------ <br /> ei i3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT fss 21677 Rev.rns 3M <br />