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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 7FOROFFICE USE:------------------------------------- --- -- <br /> (Complete in Triplicate) o._.7,,r�ff <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION...... <br /> -GLt C9_ �- ----------------------�C} <br /> �� D�'ti- -------------- - --- --..CENSUS TRACT <br /> - <br /> Owner's Name :-- <br /> -= --------------------------------- <br /> Address__ �. j l - .. Phone - -------- <br /> - -- <br /> - - --- - -..__J'" �. _ ----city--- <br /> - - - --------- <br /> Contractor's Nan'1e.R t" i" r Lice # <br /> ------------ - <br /> Installation will � - � � " � � •,• -"----- - - - - <br /> i <br /> serve: R dente [ -- Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel - - <br /> ❑ Other = = . . --------------... <br /> Number of living uniis:----------------Number of bedrooms.-----Garbage Grinder-------------Lot Size--- <br /> Water Supply: Public Sys te.r.n -__._ <br /> m and name______________________________ <br /> ----------------------L------------L ----------------------------------- ---Private <br /> Character of soil to a depth of 3 feet: : Sand ❑ .Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> r t` Hardpan ❑ Adobe Fill Material_._-- --------­---------------- <br /> (Plot <br /> ____-.If es, a <br /> Y type----- --------- ------ -- -- �f � <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: i {Nonseptic tank -or seepage pit permitted if public sewer is available within 200 feet,] (� <br /> PACKAGE TREATMENT, [ ] SEPTIC TANK i Size'_._ <br /> ------- ---------------------------Liquid Depth.-- --------- -----------�/} <br /> irk� ------- 1 <br /> Capacityl�-r!� ------ e----' Material- - ------------- -------- <br /> ------- - No. Compartments__._ ------------------------ 1 <br /> t' f <br /> t Distance to nearest:.Well__ ��------...........--------_----Foundation___Ze-1 ___Prop. Line__ <br /> LEACHING LINE ' (°]4 No, of Lines l _=-_._ -_. - "__ Length of each line p - --- ------ Total Length.__-7Q-- <br /> --- <br /> D' Box---I----:__Type Filter Material__ _ _ ---Depth Filter Material-- <br /> r f ------------------------------------------- <br /> Distance <br /> V is ants o nearest: Well Foundation ---------------Property Line---------- <br /> ---------- <br /> , -----SEEPAGE PIT Depth-------- - m ------ <br /> D• . - . - 'mba-- " Rock Filled Yes E] No ❑, <br /> 'Water Table Deph -f- --------------------------------- <br /> -_.Rock Si- ---- ----- f <br /> ' Distance to nearest: Weil__'_ ► <br /> = ------------Foundation-------------------------.Prop. Line----------------- <br /> REPAIR/ADDITION (Prev. Sanitation-Permit#_-----_._:_________________ <br /> ------------------ --Date �---- <br /> Septic Tank [Specify Requirements]______________ r__ <br /> n) ------------- <br /> ---.:--- <br /> ... , <br /> Disposal Field (Specify Requireme <br /> -- --- <br /> ------------------------ <br /> ------------------ *. - <br /> --------- <br /> Al �.l <br /> r <br /> existing and required addition on reverse side] <br /> 1 hereby certify that I have prepared this application and that the work will-be done in accordance with Sari Joaquin County t <br /> Ordinances, State Laws, and Rules and Regulations'of th;WScin Joaquin'Local_Health District, Home owner or licensed agents <br /> sig ature certifies the_ following: `""' P '"""' ,-- - <br /> -----{ <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 l <br /> to become subject, to Workman's ompensation laws of California.". . <br /> Signed----- -_- - - <br /> ,,. <br /> -- "�--- _Crwner <br /> BY------------------ <br /> -------------------- Title--- I <br /> (If other than :owner) <br /> �-- FOR DEPARTMENT-USE ONLY- R <br /> APPLICATION ACCEPTED BY----------------__--- _- ATE <br /> DIVISION OF LAND NUMBER______ ______________ _� ----- <br /> _ -;-;--.------ �4 '------------------- --------------- -----..DATE----------- - <br /> .. <br /> ADDITIONAL COMMENTS_.___________ ___________�> L - ­_�, <br /> ---------------------------------- <br /> ------------------------ --------=-------------- -------- ---------- <br /> - ------- - ----- --- - <br /> FinalInspection bY�- ---- ---- ---Date-- ��-- ---- ~-- -- '� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M <br /> EH 13 24 ' <br />