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FOR OFFICE USE: !/' FOR OFFICE USE: <br /> �' � ' , • APPLICATION FOR SANITATION PERMIT <br /> .........................................•- -.........._. Permit No..,�$-)Jl.�,�.. <br /> (Complete in Triplicate} <br /> .................... ..........FD <br /> �. -,Date issued-�.�.../.:�=.� <br /> .. ........ ........ ';+ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the So ln 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 anexisting Rules and Regulations: <br /> JOB ADDRESS/LOCATIO ...-6�--.�..:qL�!.�......�.1-•-.- . ...:�:_.__ . .... 6�...............CENSUS TRAL .......... .................. <br /> .. - <br /> _........Phone.................................... <br /> Owner's Name.......... <br /> .. :. !IIA....--V:���!'/.N .................... <br /> ..................... <br /> Address......:...............'...._.... ..1%�........ •�-• - 9 City.._r f-z. . p ZIP ............................� <br /> .�__.�. �1 License # �z.,�.-.ra. ..Pfione. <br /> Contractor's Name............ -......-------- '•-"""-"--""- <br /> t <br /> installation will serve: Residence Apartment House ❑ Commercial ❑ .Trailer Court ❑ <br /> Motel ❑ Other...`......... ............................ <br /> Number of living units:............/.Number of bedrooms....... ...Garbage GrinderLJ�.....Lot Size ... .. . <br /> Water Supply. Public System and name.................... . .. ...................,..,...... rivate <br /> Character of soil••to-a-depth-of•3 feet, and-Q.-:Slat - ay ❑ -Peat❑ -Sandy Loam ❑ ;Cloy,Loarn_❑ -- --- - <br /> Hardpan ❑; Adobe ill 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ } SEPTIC TANK [ } Size................................1:.........................Liquid Depth........................... <br /> Capacity 1�...... ty�............ __ Material..........................No, Compartments................................. <br /> CIS <br /> - Distance to nearest: Well....-------- .......................Foundation.......... . .............Prop. Line......................."„S s <br /> LEACHING LINE [ j No. of Lines. ....................Length of each line............::...:.: ..------"Total length .....-------------------------- N i <br /> 'D' Box...:..... .-Type Filter Material........ .:Depth Filter Material_...".:......:..........-....................................... <br /> Distance to-nearest:-Wel•I__. ...;...._ ..Fourvdation........................... <br /> Property Line..... <br /> 11 <br /> SEEPAGE PIT [ ] Depth............I....Diameter....................Number.................................. RdYk Filled Yes Q No❑ <br /> WaterTable Depth..................•--......._............._....:.. ..Rock Size.................... -------- .................. ; <br /> Distance to nearest..Well........................ ..... ............Foundation..........................Prop. Line.................. ........ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.:.................................. Date........:..:..................................} <br /> Septic Tank [Specify Requirements►._.._��,.........-..-_.-...-. ...•- ._......................... .... <br /> Disposal Field {Specify Requirements) '.......�l��i ! -i'........... . ..........._...... ... �..... �C'r"-: <br /> I <br /> 1 — - .......................•-••-•••-•••-----...._...................... <br /> _.___ _ <br /> Y .....-... +. •- .- .i ....................... ... ......:.:.........•............... <br /> 111-1)raw•existing and-required addition on.reverse.siclej..,.,_.,_,. ,4' <br /> t hereby certify that I have prepared iAhis 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; Horne owner or licensed agents <br /> signature certifies the following: it <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 /> to become subject to Workman's Compensation laws of California." <br /> Signed........ . .. ......... .... ..-------------------- <br /> ,........ <br /> .....f..:.�......Owner <br /> Title._.... .._.._ .. /.................................... <br /> (If other thanlowner) <br /> 1,/FOP/DEPARThONT USE ONLY I <br /> APPLICATION ACCEPTED BY. .. .............................. DATE .......�Zzw <br /> DIVISION OF LAND NUMBER......... DATE_.. i <br /> .. <br /> DITIONAL COMMENTS..................� .. ........................- -•..........................................................................__.._........................... ...... <br /> . <br /> ......................_.... <br /> ...................... <br /> ........................... <br /> ,I ............................................. . <br /> .....------•...................................................--•.....---.............-•-•-•.7...... <br /> .................................................... ............... . n ..... <br /> .-•--lDate <br /> Final lnspeciion b <br /> i <br /> "-• - •Z- •-� ; <br /> Rev. 71 <br /> EH 13 24 'SAN JOAQUIN LOCAL HEALTH DISTRICTPas 21°» <br />