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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - Permit.No. ..7�-��� <br /> (Complate in Triplicate) <br /> . ------------------------------------------------------ B/ <br /> r This Permit Expires 1 Year From Date Issued Date Issued ..7.7:.............. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> � n <br /> JOB ADDRESS/LOCATION ........3v .fir .-✓_ ..�- - ^- vc -..---------._.........CENSUS TRACT .............. ........... <br /> Owner's Name ------(w_ .L.cn.-LLQs.... OV- <br /> LICL.4.. ems....-................ . ........... ...................Phone ...-----..................._.-------- <br /> Address ......._ Cis ri e.........../ City ........ - - <br /> Contractor's Name --------- -7---------------- ----------------- ---......-..... ----.License # ------------------------ Phone ........................... - <br /> Installation will serve: Residence ❑ Apartment House Commercial ❑Trailer Court C] <br /> Motel ❑ Other ---J. - --`---------------------- <br /> Number of living units:-----I------ Number of bedrooms ...Z-.-..Garbage Grinder --------.... Lot Size ............................................ <br /> Water Supply: Public System and name ------------------------------------.-......-------------.................. -------Private [}� <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam 2'�Clay Loam D <br /> Hardpan ❑ 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 seepa a pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANKt7 Size--------------------- ---------------------- Liquid Depth ............ <br /> /. <br /> Capacity .. losv........ Type er;?.�l.... Material_fie"_ No. Compartments ..:4�.............. <br /> Distance to nearest: Well ... ------ ..... Foundation ---------_----.- --- Prop. Line ....--.. � <br /> LEACHING LINE [-r---No. of Lines �a g �&U- Total Length _.--1t19C2.�........... .r <br /> - ..._--...-..... Length of each line......z. .. ...... <br /> o .... Type Filter Material Depth Filter Material ....--......���.......---.-..._..,......... <br /> 4- <br /> Distance ton rest: Well ...��....7�..... Foundation ........................ Property Line .... <br /> Depth -- ---- beY. .. ... .. ... ...... .. ock I es <br /> =i <br /> Water a Pt --- -- --- - ---.. .--- ----- -. o S' e - --- -------- <br /> Distance to n st: ell .......I..:. .....-...F dati Prop. Line ................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...........--......._.......-.....) <br /> Septic Tank (Specify Requirements) ------------------..............................................................-...................................... <br /> ------ <br /> Disposal Field (Specify Requirements) .........................-........................................................................................... - - --------- <br /> ---- ------------------------- <br /> -------------------------- <br /> --- p <br /> ---_...------...-...---------- '----------------------------------------- Y <br /> (Draw existing and required addition 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 <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> .. "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become sub'e to Workman's Compensation laws of California." <br /> Signed ._._.. �. ,._....------- --------- <br /> ---------- <br /> -...... <br /> -.............. Owner <br /> ' By _-......._........-.......-.. ---------------------------------------------------- - ----------- Title . - ....... - ...------------------ --------- <br /> (if <br /> ---- ------------------ <br /> (If other than owner) <br /> R .DEPARTMENT USE ONLY <br /> " _ r25- ? <br /> APPLICATION ACCEPTED BY ...--------------_ .- - ----- ----------------------------------...---------------_. DATE ....�.......------�-�----------------- <br /> BUILDING PERMIT ISSUED - ....... .................... . ..... ............... ......................DATE ........................................... <br /> ADDITIONAL COMMENTS --------- -------------------_- ....................... --------------------•--- <br /> -------- <br /> - - ------ --- --------------- ------------------- <br /> - ----- --- -------------------------------------------------- <br /> .. - -------------- __ <br /> -... .----- <br /> FinalInspection by: ..----... -'---- ------ ---------------------------- --.................---...Date --- ------ - - -Y------...--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />