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FOR OFFICE USE: VIA, FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..--------•----- <br /> (Complete in Triplicate) ,7g <br /> Permit No. ..-.... ... .. <br /> ------•-----------•-- -----•-----"-"---'--�-------... lssued.l.0.-_!�-_?� <br /> .............. ..... ---- ............ ........ This Permit Expires 1 Year From Date Issued Date <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 Ordinonce.No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATf <br /> ± r _� ---- CENSUS TRACT:.-- ........... <br /> Owner's Name.... . . . . . 77 <br /> - ry ¢- <br /> " <br /> - <br /> " 7 <br /> -. . ... .-.--I. ...............................Phone / <br /> CAddress-... --- Qos <br /> Contractor's <br /> Name--,- -- ------------ ------- ..'License # ------li- .....Phone--------- <br /> ------ -------------- <br /> Installation "will.serve: Residence N. Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> i Motel ❑ Other--......: ',._ ......______ _ <br /> Number of livingunits: Number of bedrooms." bage Grind rinder...-_..:----Lot Size...........7.. x_1.3 ..:. <br /> Water Supply.I Public.System and name------------ ' <br /> - .. - "--- / .. Private ElYom: (- .. .�' = <br /> Character of soil to adepth of 3 feet: Sand ❑ Silt Clay ❑ Peat ❑ Sandy Loam E Clay Loam.E] <br /> T <br /> Hardpan ❑ Adobe` Fill Material _.: ....If yes, type...._------------------ <br /> (Plot <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: {Noseptic tank or seepage pit permitted if public sewer is available within"200.feetJ <br /> PACKAGE TREATMENT ( ] -SEPTIC TANK ( ] Size ------------------:------ __------------------------Liquid Depth...........---- -'-- <br /> i v . No. Compartments Copacityl ---.---Type.Czp4,� ateriaL--_- <br /> . <br /> Distance to nearest: Well......Ale_v4---------.----'----.--.-'Foundation............. .............Prop. Line.........:-.... <br /> LEACHING LINE j No. of Lines .. 0 <br /> Length of each line... �- -- ---- Total Length _ .�--------- --------- -----•-- <br /> ) <br /> D' Box.../........Type Filter Material..-1.4A --_----..Depth Filter Material-.1-'� -------------------------.----------.......... <br /> Distance to nearest: Foundation----------------------------Property Line.--................---...---........ <br /> SEEPAGE PIT ( ] be th.V._ Diameter-. "i { <br /> p --..Number----- --------- ---•--• ----- 'Rock Filler! .Yes � No❑ <br /> Water Table 'Depth----------------------------------------- --- -----------Rock Size.---... ------=------------ <br /> Distance to nearest: Well.-. A1,a_A1,C.--"---------- ------Foundation......--...........-....:.Prop. Line.........----...._-- <br /> REPA" I <br /> IR/ADDITION (Prev. Sanitation Permit#................................ .......-..........Date--.-.------ .-.......-.-.-.--------.-----------) <br /> Septic Tank (Specify Requirenentsi- ---- --'-.. ................. ----- <br /> " = <br /> ------------ <br /> Disposal Field (Specify Requirements)--------------_.- <br /> } <br /> ------ ---- ---------------- ..... ------- -------..............--•-----------. -------------------------------------- --------------------------------'-------- <br /> i <br /> --------------•---------------..........._.........-'------- .............................. <br /> JDraw 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 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 /> to become tulAect to Workmakn's�7Compensation laws of California." j <br /> ---- --Owner <br /> By..,----------------------- ........ <br /> (If ... <br /> other than owner) <br /> /F09 DEPAR MENT LISE ONLY <br /> APPLICATION ACCEPTED BY.----...... �Ll DATE .-- . l0.�1..? ...-. ..- .-. <br /> -- --------- - --------- ----------------- -- --- -- - -- ---- .. <br /> DIVISION OF LAND NUMBER...... . �..... ..... . . ..... fr ... DATE �. <br /> f <br /> ADDITIONAL COMMENTSrY�.... .....t�!. `..... ,~ <br /> Final Inspection by:.-----A ..O�_... Date ......... . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F&S 21677 REV. 7176 3M ' <br />