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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> ---- <br /> I� (Complete in Triplicate) I� 1. <br /> --- ------ <br /> ------ I1j---------------- <br /> Date Issued____.._'_S------7, <br /> f- This Permit Expires 1 Year From Date Issued ip <br /> Application is hereby made to the San Joaquin.Local alth District for a permit to construct and install the work herein described. <br /> He <br /> This application is made in compliance with County Ordinance No. 5A9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-_-_�.`t- J.1 / -' n :,; - .CNSUS TRACT--` -. <br /> = -------------- <br /> Z--- <br /> Owner's <br /> nn Phone_ <br /> Owner s Name-------- - - :'_--.-,�'�--�- <br /> 1. c� - - - - ---------------- <br /> ------------- <br /> ss <br /> --------- --- <br /> Address --- ----- g--- _.__ --- -=- � Gity� , ' P <br /> a A .__ . . <br /> Zi <br /> _ . , . .. f } <br /> �� """-- one_ <br /> Contractors Name_ 1tj',_ __ -.2 - � � _ License #. . ." Ph <br /> Installation will serve: Residence, Apartment House.❑ Commercial � Trailer Court. ❑ _ <br /> p. ; .. ..T. Motell❑-�-er --- -- -- -� <br /> z <br /> a <br /> g :_-____Number of bedr.00�s_ Garbdge Grinder_.__ ____.Lot Suez_ ¢ <br /> Number of livin• units:_..-.� f b <br /> j --- <br /> Water Supply: Public System and name__. --. __ � [+ - ---- - Private ❑ <br /> =--- .. - -- <br /> Character of soil to a depth of�3 feet: Sand ❑ ¢ Silt❑ Clay ❑ Peat❑'�andys`o m'❑ Clay Loamy t <br /> • <br /> Y Y P V, ' <br /> Hardpan ❑ Adobe Fill Matenpl__. _ ._ . If es, t e_.__._ �. <br /> [Plot plan, showing of lot; location cf system#in Elation to wells, buildings, etc. must be+p1ac,ed'^fin reverse side.) <br /> NEW"INSTALLATION:� (No septic tank or seepage .pit permitted`if publi sewer is available within 200feet �+ <br /> SEPTIC TANK "[ ] E Size_. �� , : lquid�De Depth J <br /> PACKAGE TREATMEEVT' 1\IN", ------ <br /> '• `` -------- - <br /> 1 ... is Capat Y ' = Type <br /> _r.Mot e�idl_--- - ---- .---------No.. <br /> Compartments l- <br /> Distance-to nearest: Well_---------- <br /> -----`-' -- ------Foundation--------------=-------- Prop. Li e--------------------- <br /> FIE <br /> LEACHING LINE [.] Na. o' Lines=--_--'------------ --------Length of each line---:-_--- .-----=-----.,------.Tofial Length.---',-- --# _� ------------------ <br /> -� :II -- _ <br /> i D' B�x---------?-.TYPe Filter.Material--------------------Depth Filter Material--=-------------°---:--'---- <br /> Dista ce to nearest: -----Foundation-----------------=------=-- Property Line_._---- s-------------- - <br /> . . ,._ . tr Rock F �Ied Yes <br /> N . <br /> e <br /> i <br /> _ t.. <br /> RockSiz ---------------------------------- <br /> ail <br /> .__ <br /> SEEPAGE PIT [ ] Depth ___.__. Diameter ]. Number e <br /> Water Table.De th___:_ _-__ { <br /> Distain ce;to nearest: Well--------;-- ::-'--- --- ---- Foundation-------- :Prop. Line <br /> a ! <br /> REPAIR/ADDITION (Prev. Sanitation P it#------------ - --------_ ' <br /> --------- <br /> Date } <br /> ii ,,. � .,,., � -°-------- <br /> Septic Tank (Specify Requirements)--'- --- ------ <br /> -- <br /> ---- =� r ' <br /> SIM ------------------------ <br /> Disposal Field_{Specify Requirements}-------------------,.- <br /> ------- <br /> ---------------------------------------- -------------------- <br /> ----------------------------------------- <br /> ------------ , ------ - - -- - <br /> - '_; <br /> 'j� (Draw existing and required addition.on reverse side) I <br /> I hereb certify that I have prepared this application and that.the .work will be'-d6ne-in accordance with San Joaquin County <br /> Y Y <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 perfor ce'of the work for which this p it is issued, I shall not employ any person in ch manner as <br /> to become ject n's Ca]npe sation .law of Califo 'a.'." <br /> f <br /> Signed 1 - - ------- ` --- .---- ' <br /> t- <br /> BY ----- _ <br /> Title <br /> ----------- -- <br /> IL <br /> ------ ------------- -------------- --- <br /> (If other'thah.own , <br /> y -FOR DEPART ENT 5E NLY , 4. <br /> DATE --------------------- <br /> APPLICATION ACCEPTED: BY�t-------------------- - - ---- I <br /> _. <br /> DIVISION OF LAND NUMBER'-•----------- ----------- --- -- ---------------- DATE <br /> IM <br /> I� ------------- <br /> ---------------- --------- --��;----- <br /> ADDITIONAL COMMENTS__= ------- ----------------- --------------- <br /> ------------------ - ------------------------- -------- <br /> ----------------- ------- ----- <br /> IM -------------------------------- <br /> �p --------------------- <br /> -------- - <br /> ------ •-- ------ -----------------------.--- <br /> -?� <br /> Final Inspection b � � . ... �----- <br /> '{--Date--'-?-�--- "`------'- ------------ ----- --- <br /> PY:------ ------------- ------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />