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FOR OFFICE USE: FOR OFFICE USE: <br /> -APPLICATION FOR SANITATION PERMIT <br /> -----------------•-- ............__................ <br /> - -- (Complete in Triplicate) Permit No..... , <br /> Date Issued---/--__....._--� <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 in compliance with County Ordinance.No. 5419 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.. 5.-S...... R�} .Ga 1�1................ ... . ..... --•..---- .......... CENSUS TRACT <br /> Owner's Name........I .N- - Phone .. <br /> Address---r- - 6 4 ---- ............. CitY 'Sta----- �,h.+A.�.P._h..o..n_eZ-i ----. <br /> Contracto 's Name............-............................................. License -------- <br /> , <br /> # <br /> Installation will serve: ResidenceApartment House L] Commercial F-1Trailer Court ❑ <br /> &el ❑ ' Other................... ................... <br /> Number of living units:.._....-.------Number of bedrooms..p;L.Garbage Grinder_---------Lot Size__V_55 --. <br /> Water Supply: Public System and name --- ----- ----------- .... .... ------------------------------------- -------------- ;-:------Private ❑, <br /> Character of soil to:a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan 0 Adobe CK 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 [ 1 Size........__.-- - --------- ._____...._Liquid Depth._ <br /> ,� ------------ <br /> Capacity_[�_QP.P. Type: .t._Material. ' -1 t - Jta Compartments------ -------------------- -- <br /> i <br /> Distance to nearest: Well-:-.------- .............. ._-Foundation.------ ..--....Prop. Line.........--- --------------. <br /> LEACHING LINE [ ] No. of Lines ................. .....Length of`each line.......-----------------------Total Length .....__........ - -- -------...._---- r <br /> 'D' Box.............Type Filter Material---. .............Depth Filter Material_..........................--------------------....... <br /> -. -------- <br /> Dist•ance to nearest: Well----------------------------.Foundation_..-- _----------------.-Property Line-_-----.------ ----- <br /> SEEPAGE PIT [ ] Depth.- ...... .....Diameter.--------------------Number--- ---------------------------- Rock Filled Yes ❑ No❑ <br /> Water Table Depth..-..-------_----------------- -------------------------Rock Size--- -- - ---------------- ----------- <br /> Distance to nearest: Well---------•-----.----------------------------Foundation..... ..............Prop, Line------- -- ---------....... <br /> REPAIR/ADDITION (Prev, Sanitation Permit#..-._--------------- - -- .............Date...............................--.----........ <br /> 1 <br /> Septic Tank (Specify Requirements).---- - -------- -------- �---------•----- ---_------ <br /> ---- -------- ...._... <br /> Disposal Field (Specify <br /> Requirements) .. -f Q_ _. .-,--.�--L lid•. 1 �_ '.! .._.� _�!: , _.{�,._ .; %-)'A-�rA.Lmt_..... <br /> _.....� �.. . 1.�.r. ------------------ <br /> -------------------- -- <br /> ­---------------- --------- --------------- ----------- ------------- -------- <br /> {brow 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 /> "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 j. <br /> t ecome subject to Workman's Compensation laws of California." <br /> Sign - ----- -- ---------- <br /> -- -- - -----.Owner <br /> .. ..--••------------- Title-----. <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> • i <br /> DATE .-/' X1-.7. , I <br /> APPLICATION ACCEPTED BY....... .......:... .. -------_-------------------- <br /> DIVISION <br /> ------_------------- ---- ii <br /> DIVISION OF LAND NUMBER--- - ------- -------- ------------ -----`------ -------------- .............----------.........DATE. --- ....... ------- I <br /> ADDITIONAL COMMENTS-......... <br /> n�+ +- ►y - - <br /> _ ..............................._.. _..-........... ........ , <br /> k <br /> __ - .... .......... <br /> Final Inspection b --------- ------------•• -.....--- ----Date. ,L'1 �j ...... --...--- <br /> Y - --- --- ------ ---- ------ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 21677 W/76 3M <br /> 1 <br />