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FOR OFFICE USE:'­— FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT . a <br /> . <br /> Permit No._ <br /> '• � (Complete in Triplicate). + <br /> `11 Date Issued--- ---- <br /> 6 74 ' <br /> This Pertnit 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 cor, nye with County Ordinance No. 549 and existing Rules and Regulations: <br /> CENSUS TRACT------`-- ----------------- <br /> JOB ADDRESS/LOCATON--- <br /> i <br /> Owners Na � - Phone. - <br /> a <br /> - --- <br /> -Ci Zip <br /> ---- <br /> Address-- -------.7�-- --- - tY _ <br /> 4 �� Phone; <br /> .R <br /> �-------- – License # ` - <br /> Contractor s Name_--__- ��----------- <br /> t _ � . <br /> Installation will serve: Residence LJ Apartment House ❑ Commercial ❑ Trailer Court_ ❑ <br /> 4--Motel ❑ Other------------=--- - ----------L--------------- s <br /> { t° <br /> - - <br /> Number Garbage Grinder--- -__Lot Size.....- <br /> Ng �- — <br /> of living units:__�__.�_`______ umber of bedrooms_: <br /> _ <br /> -Private <br /> Water Supply: a <br /> Public System nd name-.-__--------------_ .;-" - -------- <br /> - <br /> Character of soil to a depth-bf 3 feet: ` Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam [Clay Loam ❑ <br /> r eri --.�_- lf,yes, tYpe------------ ---- <br /> Hardpan ❑ Adobe ❑ �1 ill Material _ �� <br /> (Plot plan, showing size of"I'ot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: 'ANo.septic tank or"seep�ge .pit permitted if public sewer is available within 200 feet,) ; <br /> r XIV �X �� <br /> PACKAGE TREATMENT[ JI.,SEPTIC TANK [ Size_--------------------------------- -----------Liquid Depth-__._ _--------------A--- <br /> n <br /> ----------- --- <br /> Material = -------No. Compartments--------"------------------------ <br /> y ; <br /> i to Capautn Type-. 'rt <br /> i t <br /> ( �, t . ' line_ <br /> I ; ,. .. Distance to nearest: Well--- --� -----=--------------- -----Fob funds#ion Prop, <br /> ' Length of each line._.- ---'G-------------;-:---Total Length : -- -- --------- ----- <br /> LEACHING LINE„ ofiLines ,____ .-- j <br /> a�D; B x_ L___ Type Filter Material:_-_ Depth Filter Material-__---_I Gt-_ -- -- -------------- -'-- <br /> i �. ----- <br /> ! Distance to nearest: Well Foundation--'. __. Property Line _-_- <br /> ------------------ <br /> - -__--Number------------- - -Rock Filled "Yes No ❑ <br /> Depth-- s --" -Diameter_.-_-_ -------- <br /> SEEPAGE PIT V;� - r ' / <br /> '"Water Table Depth--- ------- Rock Size: <br /> Prop. Lirie -`-�----- <br /> Distarice to nearest:'Welf -0./f�----------- """- Foundation____. G_ f t <br /> REPAIR/ADDITION (Prev-Sariitation-Per"mit-#�- -- ------- -------=-------------Date--------.-----=----------------'--'-==---------} <br /> i <br /> i Septic Tank (Specify Requi'rements)-----r------= ------=------==----=---------- ------------- ----------------------------------------------- <br /> Disposal <br /> ---------------------------- -- <br /> Fl - ------------------------------ <br /> Disposal Field (Specify Requirements)'----__ :-----=------- -- -----'------°- ------------- ------------- <br /> 1 ---------------------- -------- -------• .---------- _ .- <br /> ------- ---------------- <br /> -------------a»Lt7U." <br /> --------------------------------------------------------------------------------------------------- , <br /> ---------- <br /> ------------ <br /> ----------- <br /> ---- ------ _+ 4 <br /> t (Draw existing and required addition on reverse side) E <br /> I hereby certify that I have_prep.a[eclihi p��ication_and that the work will be done in accordance with San Joaquin County <br /> t Ordinances, State Laws, and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the fallowing: <br /> "I certify-that in "the performance of the work for which this permit is issued, .1 shall not a pi y'csny person in such manner as <br /> to become subject to.Workman's _Compensation laws of California.'' <br /> f <br /> ---------Ow <br /> nor a <br /> Signed <br /> Title- _.- r <br /> ,— <br /> '(If o+ r thanown <br /> . er <br /> i ' { FORMEPARTMENT USE O 1 Y°" <br /> 3D ------ <br /> APPLICATION ACCEPTED BY------ - <br /> ATE ----- <br /> - <br /> t � � _ � --------- ----- --------------------------------- <br /> DIVISIONOF LAND NUMBER ------------- ----- ----- ----------------------------------------- <br /> ADDITIONAL COMMENTS------- ---------- <br /> ----------------- --------- ------------- <br /> --------------------------------------------------- <br /> s <br /> --------------------------------------------- - <br /> ------------------------- ---- ---------- <br /> S ---- ' <br /> ---------------------------- <br /> -------71 -­ <br /> Fin Date - <br /> I -Inspection•b <br /> ------- --- - - - -- <br /> ---------------- ------------ <br /> EH 13 24 SAN JOAQUI LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />