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FOR OFFICE USE: FOR OFFICE USE: I <br /> z APPLICATION FOR SANITATION PERMIT <br /> �_C g, <br /> .`.,,(CompletdAn Ica <br /> Permit <br /> � a <br /> Date—issued--- 7 <br /> ----------------- This Permit Expires i 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 C unty Ordinanc No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.... --- _.___.CENSUS TRACT----._'------------------- <br /> OwfieC.S�Name-= - one - -S <br /> Address _ S <br /> T City ZiP ---- ---- I <br /> _�h <br /> Contractor's No -------- l Phone'_ <br /> license #.. .:�sS�_ � <br /> Installation will serve: Residence ❑ Apartment-House-[]---Commercial Trailer Court E) <br /> I k ----------------- <br /> Motel F­1 Other <br /> Number <br /> of.l'iving units: -.- Number of bedrooms -------_ .Garbage Grinder... -_.Lot Size-.- <br /> WaterSupply: Public ystem and name----------------------- ------ -----------------------� _ - -- - __.-. ------------------ Private". <br /> �` E <br /> i - <br /> Character of soil to.a,depth of 3 feet: tSdncl 0 •t❑ .IcjayOJ Peat❑ Sandy Loam ❑ CIS Loam <br /> 7 i, Hardpan ❑ Adobe ' Fill yes, type---------------- <br /> (Plot plan, showing sizefof lot, locationofsystem in relation to:wells buildings,:e-iL.must be p!ed on-reverse side.) <br /> NEW INSTALLATION./— _(No`septic tank .or seepage pit permitted ifpublicsewer is available within 200 feet,). . , t <br /> [ ] SEPTIC TANK [ ] '�j Size-Size ^ r��-��_�-_- ____-Uquid�e ftli_ <br /> PACKAGE TREATMENT� + - :' r `_ - 'T�----------- -- <br /> 1 <br /> Capacity' ?. �TypeMateriaL __No: Compgrtments _.____. '____-_----------- <br /> .Di sta nce-to-decirest:-.Wel 1./J. -640------ <br /> . __Distance-to_nearest:..WeIL/640------ Foundation, /a,--- =-.Prop. Line-_.:�.__ <br /> LEACHING LINE [l�No. of Lines--------- � 1'en th of e ch fine _ �S� _ Total Len th; ._�c� e) <br /> 9 -------- <br /> 'D" Box_ :_.. __ Type Filter Material_ / . _ /Depth Filter:Matenai _ (_ k __ <br /> OG � <br /> ... - -dam � ,. � .L./.:..�t a -t--r � tr , . <br /> i Distance to riearest: Well._ Fo1al�dation � __ --Propert �Li�1e S -- <br /> SEEPAGE PITDiameter 4:;2 ..... Rack Filled Yes �No ❑ <br /> i.. P Y --�._'f ize ( 21k-3-=-- #'� ' <br /> 1rWater Table�De 'th a _.-- Foundation'_ock5 <br /> Distance to nearest: 1Nell__-- __ . - .�T�-- _s `_.Prop. Line--�--�E`----- <br /> REPAIR/ADDITION (Prev.-Sanitation Permit#------------------------- ___ Date_._._-_I'---­-------------.--- <br /> .___.,____:___.._.._ _-___ _______ <br /> Septic Tank (Specify Requirementsl----------------=-------------- <br /> ----------- <br /> Disposal Field (specify Requirements)" ------ <br /> --------------------------------------------------- ----------- - ----- -F ---------- ° -- <br /> # i <br /> .. - ----:----------------- ---- --------- ------=--- -------------------- ' <br /> ---- ---------------------------------=-------------__---- ---------------------------- ------------------------------------- - --- <br /> (Draw existing and required addition on reverse side) Y <br /> I hereby certify that 1 have prepared this application and that:the-.work will be done in accordance with--San Joagilin County <br /> Ordinances,' State Laws, and Rules and Regulations of the: San Joaquin Local Health District, Home owner or-'licensad: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 mann r as <br /> to becom4 jec to Work n's C mpensation laws <br /> of._California."-. <br /> Signed_ ---------- -- --Owner <br /> By-1-------.---- --- -- Title- <br /> ---+ --- _ . i <br /> ------ ---- - <br /> (If other tha er <br /> i� <br /> ° <br /> FOR DEPARTMENT'USE ONLY _ ► <br /> APPLICATION ACCEPTED BY_ - - --' ...... <br /> DIVISION OF LAND NUMBER.-------------- <br /> -- DATE___- ---------------------------- <br /> ADDITIONAL <br /> ____- <br /> -- ------------------------- -------- --=---- ---------------: ---- -- <br /> ADDITIONAL COMMENTS-------------------------------------- ----- - i <br /> -------------------- <br /> - - -------------------- -------------------------------- -------------------------------------------------------------�-- -------------------- -------- <br /> --------------------------------- -------- --- - ---- <br /> -- ----:-- --- --.- ----------- - - ---- ----- -- --- ---- --ff <br /> i <br /> =------ -------- - - -----------.------------------- a ------ -g----- --- -------- - -- ------- <br /> -Final Inspection.bY: __ ------ ---- Date. 1 <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />