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FOR OFFICE U FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT .rip /40 <br /> .................................... ... ...-_.- (Complete in Triplicate) s Permit No..-- -A--- :.-:... <br /> ----- ----------------------- <br /> Date Issued-J::d-`.28 <br /> .........................................I——........... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin,Lo.cal Health District fora 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 Regulations: <br /> JOB ADDRESS/LOCATION .. --- .-1_- ------ - -----CENSUS TRACT................... ............ <br /> Owner's Name.-.- 2.' - --------------- ----- Phone ....- .. <br /> Address � -- -- ----------- - ---- ------------------ ------- City Zip.-.:. .............P� <br /> rte` _._ .. . - <br /> Contractor's Name-- ��-- f;. -- -- - License #-. U.ai ._Phone-f-,2 ..-..----.�/--... ? <br /> _ I <br /> Installation will serve: ResidenceLel <br /> Apartmen House ❑ Commercial ❑ Trailer Court ❑ <br /> ❑ Other-- - - -------- -­-------------------------- <br /> Number <br /> --------- ------------------Number of living units:..../ =Number of bedrooms....-:.Garbage Grinder------------Lot Size--------f ..:......:............ <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 ❑, 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: (No septic tank or seepage pit permitted'if public sewer is available with'sn 200 feet,) <br /> TANKFLiquid Depth..-::------............ <br /> PACKAGE TREATMENT SEPTIC <br /> _l — <br /> Mataial ----- ---- - <br /> No. CompartmentsCa <br /> Capacity . <br /> Distance to nearest: Well.:... ................... --Foundation..---- -- - --........ Prop. Line---------------------------. <br /> LEACHING LINE ( ] No. of Lines... .................-------.Length of each line. Total Length -.._----I------.-----.-----.---------- <br /> 'D' Box--- ;,:...Type Filter Material.............. Depth Filter Material-.- ----------------.------- ---�.-----.-.---------.--...-• <br /> I C_ -a_ _. <br /> Distance to nearest: Well.......... _. Foundation-------...-----.,-----------Prope7ty. Line--- -..--.......--,.------------ <br /> k �: <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#--------------------------- ....... -. - Qate. ---•------------- -----] <br /> i Septic Tank (Specify Requirements)-------- -- ----------------- - ------ - ---- ------ 1 <br /> Aon <br /> Disposal Field (Specify equirem nts)-..- .. ..•_.. a ......' �.. _..-.. . -------- ------ <br /> -------.._.-- --------�------ •. <br /> ------ ------------------ ------ ---------- - <br /> {Draw 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 Son Joaquin Local health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "1 certify that iii the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed = - ............. <br /> .- -.Owner <br /> By----------- <br /> Title _... <br /> . (If other than owner) / <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -: DATE .: --. --` - ------- <br /> DIVISION OF LAND NUMBER---:........... ------DATE.--- ------ - --- ----- - -- -------- ---- <br /> ADDITIONAL COMMENTS....--- - - -........------------ ---- ------- --- ----- ---- -- <br /> -- ----- --- <br /> ------------- -•---- -----. ------------------ --- -- <br /> -.-. --- ------------ ............... .............. .-...---------.--------...----._- -------•------------- - <br /> ----- -- --. ... <br /> ----------- <br /> ...- --.---- <br /> --••----------•-- ----- - . ----- <br /> Final Inspection by:..... -------------------- -.- __. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s ai6n-Rev..�i�e inn <br />