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FFICE USE: ✓ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ,• - �j <br /> ------------------------- -- ----------_...-._..__. . <br /> (Complete in Triplicate) Permit No._ d......- <br /> - Date Issued.! <br /> .................................... ......... - I 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, 549, and existing.Rules and Rula�n.5.; <br /> JOB ADDRESS/LOCAT N..--.. <br /> P �. ./ . . ----------- ----------=CENSUS TRACT.......................0 _Owner's Na -------. . ....................Phone <br /> -- -- ------------- ------ <br /> Address------- -- D �`� r u .tom Ci ----- --------------Zi <br /> Contractor's Name---:.... .. � v +. . Phone... � <br /> __. . C -----.Licnse -�----�--- l s <br /> ------ 1 <br /> Installation will serve; Residence [R� E]Apartment.House Commercial Y Trailer Court ❑ %�f l 'fr`" t`� <br /> Motel�❑ Othlk <br /> e 44 . . �. <br /> Number of living units:;_..:..-..__Number of bedrooms..,V- - Garbage Grinder---Q.._--Lot Size.__ <br /> Water Supply: Public System and no ie.. . _ ---•- -------- -------- - ---- •----.:....,__.-...---------------------------------- --------- -- - --•------------.Peivate <br /> Character of soil to a depth of 3 feet: ii Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam 1-4- <br /> Hardpan <br /> -- <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: i (No septic tank or-"seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [yl' "' ..__._:.'SJ ��..k�....... ...... ... .......Liquid Depth. ..1rr----------+ p _.....Capacity-.8� -- ------- Type..l4 ...._eize <br /> s Material_:.1 -tl_vi e �-.:No. Compartments...-- .--,--..-. <br /> Distance to nearest: Well_;--------0....._ ...Foundation:_ ------ - _.-_ Prop. Line.....!!r/....... <br /> . <br /> . . .. _ <br /> .............LEACHING LINE [vrNo. of Lin <br /> es. -------------- _._. Length of each line-------- Total Length .. .-p..... <br /> D' 1JI/ - ------- <br /> --------Box. Filter Material. .�.°...*-De th_.Filter-Material..... -...--. .. -- �7� <br /> 1 <br /> Distance to nearest: Well--y.._..-`.'..................Foundation.....�-----•---.---.---....Property Line.--.;�--.,--....::-----------....... <br /> SEEPAGE PIT ��r +� . <br /> [ Depth_.._�-5:._._Diameter..�...��.� ...Number._�_�__�___................' Rock Filled Yes��No❑ <br /> �- l . . . . I ; r� <br /> Depth.---------- 1 Rock Size. �.� �..----- --- ....__ .� <br /> ter <br /> ��" °- Pro Line. f --------------- <br /> Distance ato nearest: Well.-._-._.-_f__. _ .........Foundation......../.. ........... p. <br /> REPAIR/ADDITION (Prev, Sanitation Permit#----.-----------. .._....._._Date........:.......... .._---__} : a <br /> Septic Tank (Specify Requirements)_---- -- ------------- - <br /> ------------ - <br /> Disposal Field {Specify Requirements)i................. . ------.-------------- ...................... <br /> ---- ... ----------------- <br /> s � <br /> I <br /> ......._.--....._---------------------------------------- --"---......----'--...-..-....��-------_-_---•--....._-...__•--_-•-------------••-..___:._..._......---__•-___..._.._......__...... - I <br /> (Draw existing and required addition on reverse side[ 4 <br /> I hereby certify that I have prepared1this application and that the work will 'be done it accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules p and Regulations of the San Joaquin Local Health District. Home owner or licensed agents l <br /> signature certifies the following: i <br /> "I certify that in the performance of.,the work for which this peYtmit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California.". <br /> Signed.......... Owli �. <br /> BY..---- <br /> - - Title¢--:..._ <br /> (If other than, owner) _ ? <br /> 1 PPR D PARTM T USE ONLY <br /> APPLICATION ACCEPTED BY /� <br /> �- <br /> BATE . l - a g ?...........-------- <br /> DIVISION OF LAND NUMBER. .............. : ............. DATE l <br /> ADDITIONAL COMMENTS - --- ----------------------------- -- ----------------------------------------..................-. _ <br /> -------------- __.... ------- ----------- ..- <br /> } ------------- --.....-- ..--..... <br /> ....---..... -------- --------------- -- ----- <br /> ---•----... --- <br /> --------------- -- ------ <br /> Final Inspection bY---------- --------- ----- ) ��, <br /> .. . ----- --- <br /> ....Date..:..:. � . °1-.7 - ----------EH 13 24 SCAJOAQUIN LOCAL HEALTH DISTRICT F� as+s1677 REV. r/7e 3M: , <br />