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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 0 <br /> ----- -------------- - - ---- -------- - --- No.�.�'--`� <br /> (Complete in Triplicate) Permit <br /> ' Date Issued,-5_-11)_' <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS//LOCATION_ d-f-Y_-S- v ---- ..---��l fix._(r� �---- 5 �-�a----------CENSUS TRACT-------------------------,--- --- <br /> Owner'sSName(. ` jE4Y C`e------- -- -- -------- ------ ------------------------- --- -------------------------- ---- ---.Phone__ . -= 7 ------- <br /> T <br /> Address �5!f--.- = Q '1 - Y .0 City ZiP 22o <br /> Contractor's Nam�----------------------------------------------------------------- -- -- ------License # -----------------------Phone------------------------------- <br /> Instailation will serve: Residence ❑ Apartment [douse F1 Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_/kA .1r,_,,-_-------..:--------------- <br /> Number of living units:- --__l---Number of bedrooms--:P------ Grinde+�----Lot Size.-J 44Z_1 ----------- <br /> WaterSupply: Public System and name ------------------------------------------------------------ --------------------------- --- ----------------- ------------------Private <br /> Character of soil to a depth of 3 feet: Sand..❑ 5i t❑ Clay ❑ Peat ❑ Sandy.Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe FiII Material--.---------If yes, type------------ _------ <br /> (Plot plan, showing size of lot, location of system in relation towells, 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 [ ] �`i _,-Size Liquid Depth --------------------- --- <br /> Capacity la --_T 't�blVate ial -------------------------No. Compartments-----�----------- �i-- <br /> Yp�,' - <br /> nearest: Well ------------------- ---- -`------i..-Fou4clatlon.- Prop. Line ' <br /> LEACHING LINE [ ]. No, of Lines f <br /> istance to <br /> Lengt Qf each line.---_- Q_,___:\`::_.--___.Total Len th -G 5 <br /> D' Box--=/__ ---Type Filter M'aterial._.--_`� =Depth Filter Material:_ -------- ---------------------. <br /> P, <br /> is Foundation_-- ------- <br /> Distanceto nearest: Well-; -----_,- .----- .-.- Q __=---.Property Line..-- 5__-. <br /> SEEPAGE PIT [ ] Depth-----------=----Diameter-;------:---------- Nurn6Qr------ ------------------------- Rock Filled Yes ❑ Noi <br /> . A ,�Depth <br /> - I ` ` -------- --- e -------------------- <br /> WaterTab}e -:-- <br /> Distance to nearest. Well-1-1------- mo ---------;-_-_.Foundation ------------------------Prop. Line--:__------------------�-- <br /> Liu <br /> � <br /> :.. <br /> REPAIR/ADDITION (Prev, Sanitation Permit#-------- -------------------'_ - -------=----.Date-------------- ---------------- ) <br /> Septic Tank (Specify Requirements)--- - --------------------=-- ----- ----------------- ------------------------------------------ - --------- <br /> Disposal <br /> -- ---- <br /> Disposal Field (Specify Requirements)------------------ ' --------------`------- ------------------------------------- ---------------------------------- <br /> j--------------------- --------- <br /> ------------------------------ ---------------=------------------ <br /> 1--------------------------- --------------- --------------- -------------------------- <br /> (Draw <br /> - -------------------- <br /> (Draw existiing 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 County <br /> Ordinances, State Laws, and Rules and Regulations of,-ithe San Joaquin local Health-District. Home owner-or' licensed-agents <br /> N. <br /> signature certifies the following:-- <br /> i "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 /> I to become b' ct kman' Compensation laws of California."' <br /> Signe ----- ------ -------- Owner <br /> 1 <br /> -----------------------------Title------ -------------------- ----------------- --------------------- ----- <br /> (If other than owner) i <br /> FOR DEf'� MENT USE ONLY <br /> APPLICATION ACCEPTED BY-- --- ' -- ------L----------------------------- - --DATE. -7=- --------------------- <br /> ` <br /> DIVISIONOF LAND NUMBER----------- ----------------- ;------------------------ ---------------------.--------------- ------- DATE------------------ ----------------------------- <br /> ADDITIONAL <br /> ----- ----ADDITIONAL COMMENTS--------------------__------------3---------------------------------------------------------- ------- ----- -------------------------------------------------------- <br /> ---------------------=--------------------- - ----- ---- - -` --------- --- ----- <br /> Final Inspection by:_. at fgS 23677 REV. /7- 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />