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1 FOR OFFICE USE: ( FOR OFFICE USE; <br /> I yp APPLICATION FOR SANITATION PERMIT <br /> — > <, �9_-.�-�Ea <br /> Z \ a� (Complete in Triplicate] Permit No. <br /> � <br /> .......I.................. ...... .. ....... <br /> -... %; Date <br /> i .......................... ......__._.------ ......... This Permit Expires I Year From Date Issued <br /> I. 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.M;7D.Ov.. ,�, 11 ..,.r-.../..... �a70....... .........................CENSUS TRACT.....-- --.................:.. <br /> Owner's Name... . .... ...._... . GA.I / / Phone. ....... <br /> .. :........................................... ... ... S3 <br /> Address.... Q-A3.. .. ..-�..� ... . City-/.... . ......... _Zip.. _.. .......... ....... <br /> Contractor's Name.....:... License #.a.� e.. "--���1 <br /> �? Gf..`. -<�- - - ----- .._.... -- ...... f. Phone....._.:------------ _._. <br /> Installation will serve: Residence❑ Apartment House_Q Commercial ❑ Trailer Court ❑ <br /> ' Motel ❑ Other..... -d- . <br /> Number of living units:. `..'...Number of bedrooms............Garbage Grinder.........:..Lot Size-../. � <br /> _. ........................... <br /> Water Supply: Public System and name............�....----........._ 1..................:.................---..............__..------.............:_.-- rivate�' <br /> t P ' <br /> Character of.soil'to d depth bf 3 feet: Sand Silt ❑_' Cloy`❑ Pest❑ ` Sandy Loam b Clay Loam❑— <br /> f Hardpan ❑ Ado6e❑ Fill Material..,.... ..'.If yes, type............................ <br /> ... <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 seepage pit permitted iif�public sewer i}avail le within 200 feet,l / Q <br /> PACKAGE TREATMENT SEPT ICrTANKSiz ..7. .�-Z /. c�- .- 9 P //// --- <br /> ov �'. <br /> Capacity. �r ...............Yype.. ...:� ....Materidl.4�✓ ..-- --No. Compdrtmorrts'"_...-: <br /> . . <br /> 'Distance tonedrestq: Well.../4 Z..... Foundatio/n.. . . .........:..:Prop, L/ine......-__......... .... <br /> LEACHING LINE [f<No. o} Lines' ......el................Length of och IineU:�6.d..f.�.`Q. .Total Length - /-.g <br /> ... dQ '� <br /> ( 'D' Box. ...Type Filter Material`T.t. . OjMe....Depth Filter Material......./.CJ........................ <br /> Distcinceto dearest:-W�ell, _60—___..-._FouAdation..Z4..................Property Line...> .... . .......,............` <br /> SE� l�'1�� Depth... .[?...:.�Diamete ...`.A4� ?O..Numb-er........ ............------ '/ iI ock Filled Yes [6]�No 5" <br /> 22 i , <br /> Water Table Depth...........04 .........................-�--,---.Rock Size...C;2X,31....-- --------..........._ --- 1 <br /> r <br /> Distance to nearest: WeII/QQ...._._............. Foundation....Z.4...... ......Prop, Line---- ..._ ..._..--... <br /> jREPAIR/ADDITION (Prev. Sanitation Permit#.. ...................._.....---.. ._ _---------Date--------.......-............................ <br /> 1 <br /> Septic Tank (Specify Requirements)._--- ..................................................... <br /> Disposal Field (Specify Requirements)_-_------............- - ---- ................................ <br /> ............ ... ._. ................................... <br /> ............. ..`. .i .. .... ... ............ : <br /> ------------.. .......... ' <br /> r - -- <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 County <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District, Home owner or licensed agents <br /> r signature certifies the following: ;I <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 as <br /> l0 Leto a bj ct toWo I an's ompensation laws of California." <br /> Signed ... .... - _ .. . r .............Owner <br /> C � Title... <br /> ....By..............---.._.............. :. Of ` r1 ---. -. .... . . . __ . ...... <br /> .._..... <br /> i (if other than owner) <br /> F PA MENT S NLY <br /> APPLICATION ACCEPTED BY----------- ..DATE ...... ... .... .... ... ..._ ._..._. <br /> DIVISION OF LAND NUMBER _. ............ .._.. ....DATE......... ,......... ....... _......_,........ <br /> ADDITIONAL COMMENTS...-- ------------ -------- - ..............._.........__._..-. <br /> - ............ - . ...... <br /> ............................................... ...... ............................................ ---------.------------.--------- ----.------- ............ ....... ................. ........ <br /> - ......................................................... ................................................................... --------- - ---....--........................-.. ........... <br /> f ..-........- - ........... - _.. ... .. - ....... . ....................... <br /> ..... - -- - ..-...� .. .......... <br /> 1 Final Inspection by:... - ..........._......... ................ ...................Date... _..... <br /> ...Y. 0 -- !- ..r. <br /> y <br /> EH is 2e SAN AQUIN LOCAL HEALTH DISTRICT Rls si6n REV. 7/� <br /> f �V <br />