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FOS:OFFICE USE: APPLICATION FOR SANITATION PERMIT r <br /> �__ Permit No: <br /> �� -------- <br /> 1�= `� AComplete in Triplicate) <br /> ---------------------------------- % Date Issued/,74 <br /> This Permit Expires 1 Year From Date issued <br /> c <br /> Application is hereby made t <br /> sm <br /> ade in co pliiancewith County tOrd non a Nominstall <br /> 549 and existing 9 Rulesand Regulat onsf e1n- <br /> described. This application <br /> .----- - <br /> ' CENSUS TRACT - ---------- -•------•- <br /> JOB ADDRESS/LOCATION �. <br /> Phone <br /> OL ----------- <br /> Owner's Name -----7------y------ i' City - ------------------------------- ------•------- <br /> Address ----------, , <br /> - (� <br /> Contractor's Name ---------------- License <br /> Phone ------------ <br /> ------- -- <br /> --- ---------------------------- <br /> Installation will serve: Residence Apartment House�� Commercial Trailer Court 0} <br />! Motel [I Other ------=------------------------------------ <br /> Number of living units:.---'._.... Number of bedrooms - ;2-+__.Garbage Grinder -----..-_-- Lot SizeF_,�� <br /> Private <br /> Water Supply: Public System and name -------------------------------- - -:` '--- <br /> Character of soil to a depth of 3 feet: Sand'[1w . Silt[] Clpy , Peat❑ Sdnhdyoa [] Clay Loam <br /> Adobe Fill Material< _ ----n If yes;type --'---------•-------- <br /> y <br /> Hardpan ❑ E � <br /> [Phot plan, showing size of loft, location of system in relation�ttivells, buildings, etc. must be placed on reverse side.) <br /> LV <br /> NEW INSTALLATION: (No septic tank or seepage pit mitted if-public sewer is available within 20d feet,) <br /> V. V <br /> PACKAGE TREATMENT [ ] � F. <br /> i Liquid Depth arjf <br /> SEPTIC TANK' ¢`` Size -- i- = ; 'V <br /> �� <br /> No. Com artments ____.•-------•- <br /> Capacity 1kUv-- Type - `� `_4:"'Material P <br /> I <br /> . Pro Line ---------= --------- <br /> ll Foundation- fQ P• C <br /> ---ter <br /> J-- --• <br /> nce to <br /> - -_--L•en th-of•eac line---- -��---- - ------- Total Length :----�-�...--• - -- <br /> LEACHING LINE �: No. ofLines nearest: Well <br /> g � � I e� <br /> _Depth Filter Material - --1- ----------------------------•=-•- <br /> 'D' Box ---------L_ Type Filter Material - -- '- ---- -- <br /> 1 �- l I O —--- Property Line ------------------------ <br /> Distance to nearest: Well --- ----3_��- oundatian ---- --------------- <br /> + � t I <br /> �__--,_- _. Rock Filled Yes No iU <br /> - Diameter? - ' iNumber- -=--------- - <br /> SEEPAGE PIT Depth Z - ------ <br /> ) <br /> I --=-Rock-Size _�-�._�� z ly------ <br /> ------------- -----o------. 4 sem._-► 'f <br /> Water Table Dept - - -.► <br /> -------..__Foundation . Prop. Line <br /> Distance to nearest: Well -----/OD-- i VV k <br /> . . ----- Date ---- ------- <br /> REPAIR/ADDITION } <br /> (Prev. Sanitation Permit --.-------- = = ---"'"'" -- %Iat <br /> t <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------ -- ----- ----- <br /> Disposal Field (Specify Requirements ------------------- <br /> ------------------------------------------------------- <br /> ---------------- <br /> ------------------ <br /> --------- <br /> -------------------------------------------- <br /> ------ ------------------------- ----------------- ------- <br /> (Draw,existing and required addition on <br /> ------------------- <br /> 9 ------- --- --- ------- -----�-------------------------------- ------- -- on reverse side) <br /> 1 hereby certify that I have prep ed this application and that the work will be done in accordance with San Joaquin <br /> ' County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents sign aturetcertifies.the following: <br /> "I certify that in the performance#of the work for which this permit is issued, I shall not employ any person its such manner <br /> as to become subjectto Workman's Compensation laws of California." <br /> Signed --- -------------- ------------- Owner <br /> ----------- ---------- <br /> ri ------------- ------------ <br /> r <br /> Title ---- <br /> (lf other n owner) <br /> N11IR DI PARTMENT USE ONLY <br /> ' DATE -`-- -- --------- <br /> APPLICATION ACCEPTED BY------f_- <br /> --------- DAT <br /> BUILDING PERMIT ISSUED..�'�------ ------- - -- <br /> ADDITIONAL COMMENTS ------------------------ -- <br /> ----------- <br /> ----------------------------------------------- _­­- <br /> ---- --- ---------------- -_ ---------------------------------------- <br /> --------------� --- <br /> i <br /> ` Date <br /> ------------------------------ <br /> Final <br /> Inspection by: -----� ----- <br /> f <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> E. H. 9 1-'6$ Rev. 5N1 - ..... - <br />