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FOR OFFICE USE: FOR OFFICE USE: <br /> /APPLICATION APPLICATION FOR SANITATION PERMIT t <br /> ------------------------------""......... . ..........__. g gp; <br /> (Complete in Triplicate) Permit <br /> ......................................................... <br /> Date Issued-je..'."W-2 5w, <br /> .......................... This Permit Expires 1 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 incompliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> -------------------.CENSUS TRACT--------------- <br /> JOB ADDRESS/LOCATION....���.._c.�_�--1��. ..._...... . <br /> 00 Owner's Name...... 1 -/ .h� lv.~ .../'T-.t ------------------- - ---------------------- --------------------- ---. Phone-./G�:,_:, J ... <br /> Address ... City � ��. <br /> Contractor's Name............... .............. ......................................... ......License #--------- .............. Phone.-- ... ------------ ........ <br /> Installation will serve; Residence [X Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_- ------------------------------•------ <br /> Number of living units:------ Number of��b++edro/loms-..3-....Garbage Grinder------------ Size--- =---•--- ...... <br /> Water Supply: Public System and name--- ........W_ #Aex.................-------------- -------:.-------- - - ------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill 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 I ) Size.-- ------------ ------------.-Liquid Depth._'::_........__;...._--- <br /> Capacity/.A_2Q --------------------------No. Compartments...r ....................-........ <br /> / r� Prop. Line. _� FT <br /> Distance to nearest: Well.:..�D.��-.........-...........Foundation.. __Q_.. ."--...--.. / ......... ---•U] <br /> LEACHING LINE [ ] No. of Linesth of each line..... 6--------------_. Total Length .......$.Q__.............._"--.--� <br /> 2 Length L , - <br /> 'D' Box..-/-....Type Filter Material....)A .__-..-- Depth Filter Material-._.1.2...--.--_-----------_--. .. <br /> F j <br /> t <br /> Distance to nearest: Well--/�Q'�..�.... - Foundation----- -Q---------........Property Line".-_/ ----------- ........... <br /> I_ <br /> // U <br /> SEEPAGE PIT ( ] Depth._13 ......Diameter--�--`�__---.Number....... Rock Filled Yes a No ❑/ <br /> Water Table Depth-----------------------------------------------------....Rock Size...--- .------------------ --- <br /> Distance to nearest: Well------kjT _xo------- "".............foundation............... ..........Prop. Line-----------.............. <br /> -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------`.. -----------------------..:..Date------------------. ------.............. --..) <br /> Septic Tank (Specify Requirements)---- ------------ ---------------- ...............I—........ <br /> Disposal Field {Specify Requirements)... ..... - ------------------ -----------............... <br /> ------------- " ........ ----------- ------------------------­----- - ............. ---- -- ---------------- --------------- --------- <br /> (Draw <br /> --------- -. -- <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 San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "1 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 blect to Workman's Compensation laws of California." <br /> U <br /> Signed-—r_.,, .. --- --------------------------.--Owner <br /> 8y_� �".lL..l�, -- •• --------------- - <br /> ---.-Title--........ ------------------------------------------------------..... -- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- r444 - .M?.------------------------ ----------- --------------_....DATE ............. <br /> i DIVISION OF LAND NUMBER----- -------- -- - ----------------------------" DATE.----- ------------ .--- ......... <br /> P �� ��cl. _y..._ - . log ... -- --- ------------ ...... <br /> ADDITIONAL COMMENTS....._..." ►?� <br /> :.. .. .. ...... �:.. ------------------------ •----------- <br /> Final Inspection b ------?---------- ------ ------•- ..........- .-Date-...� --� ... <br /> E►+ 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76�M <br />