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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT (j <br /> ` (Complete in Triplicate) Permit No7 -'.P.`/--- <br /> ----------- ----- --------- - - ------- ----- 4 <br /> Date Issued.��". -?.... <br /> 6a....................___..........._.......__....__ 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 /> L <br /> JOB ADDRESS/LOCA N -L- -Z--?I--�----..X---- --� Q.-- .----------------CENSUS TRACT---------...._-._..-----..... <br /> Dwner's Name.----- l/-- - - --- -g- - -- -- - -- ------------- ----------------Phone-------------------------------- <br /> �Address.--------------- �7 2 �'l -- -- <br /> -.--Ci T)- ' -- - Zip----- <br /> `� ,> <br /> Contractor's Nai -- ------ ----License #--3-;2�9 2 D-4Phone----------------- ---------- -- <br /> `Installation will serve: Residence ❑ Apartment House❑ Commercial F1 Trailer Court ❑ <br /> Motel ❑ Other__----- <br /> Number of living units:------- --_...Number of bedrooms-----j---Garbage Grinder------------Lot Size-------- ---A-e— %. -------- <br /> `..+Nater 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 [9 Adobe ❑ Fill Material------------if yes,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: (No septic tank or seeps pit permitted if ublic sewer is available within 200 feet,) <br /> / / / / <br /> .PACKAGE TREATMENT [ ) SEPTI/CgTANK [ Size,./ ._Xp__f�.___ .- .__._.__..Liquid Depth.__..----------- - <br /> � <br /> Capacity-/,441.D._...._.Type_ Material._4 r`.-:¢.f...___No. Compartments....7------------------- <br /> -_� <br /> O _Foundation-...--- /'.-.Prop. Line.J-^�__..___ <br /> rI � <br /> - - <br /> Distance to nearest: Well.............-�_.-__ . _ <br /> LEACHING LINE [�No. of Lines.._.....__.3_ ---- ----- Length of each line------- -P __Total Length._.._1_z6_ --_..__.___.J <br /> 'D' Box----/------Type Filter Material------`Z.12-----Depth Filter Material____/_f.___ ---------------._._..__..__....._.__._.... <br /> Distance to nearest: Well-----_S_Q._--.....-.Foundation......:..,L:_-----.__.._Property Line--------- <br /> . <br /> J.__.____. <br /> SEEPAGE PIT [�] Depth....2.r-_Diameter...___3-3-----Number...___..3-_-.___- Rock Filled Yes No ❑� <br /> ._-_ /..-___-....___..Date_........_._::_.. t3 / <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------- _______--__ <br /> Water Table Depth -___...._/_P�..-_..?-'-.___............._..Rock Size---- <br /> Distance to nearest: Well_...____/.O_ __ ------------------Foundation---_-l_.____._.-_.Prop. Line-------- <br /> Septic Tank (Specify Requirements)-------------------------------------------------- ------- --------------------------- =----- <br /> Disposal Field (Specify Requirements)------------------- --------------------------------------------------------------------------------------------------------------------� <br /> --------•=------------------`---------- -- ------------------------.._.._-------- ----------------------------------------------------------------- ------------------------------------- -------- <br /> ----------------------------------------- <br /> � <br /> t. <br /> (Draw existing and required addition on reverse side) It <br /> I hereby certify that I have prepared 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 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 <br /> .do become subject to Workman's Com ensation laws of California." <br /> Signed..... - - - -- - - - - ---- OwneryrY2� <br /> J - <br /> By-------------------- ---- /6? s�l am] -_...Title- " -------- -------- --- <br /> ....------- <br /> (If other than owner) / <br /> FOR DEPARTMENT USE ONLY -7 <br /> ,APPLICATION ACCEPTED BY f -- - - - - - ------ - DATE. - /---------- <br /> DIVISION <br /> - -DIVISION OF LAND NUMBER --------------------------------- ------------------------------------------- --------- DATE- ----------------- ----- - ----------- --- <br /> ADDITIONALCOMMENTS--------------------------------------------------------- ----- --------------------------------------------------------------------------------------- <br /> -------------------- ------ ---------------------------------------------------------------------------- <br /> --------------------------------- --- - - - - - - - - <br /> Final Inspection by:__.....- --- - -- - -- - - '°s�----------------------------------------------Date.-----CC.---_ ---- -- <br /> - -- --- <br /> -.EH 13 24 SAAV JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV.7/763M <br />