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ry � <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICAT16N FOR SANITATION PERMIT <br /> ------------------------------- <br /> -------------- <br /> (Complete in Triplicate) Permit <br /> Date Issued___ _ - J- <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. 549 and existing Rules and Regulations: ' <br /> JOB ADDRESS/LOCATEON.--- -----` `- - _ U �� --_ <br /> -_-- ' CENSUS TRACT------ ----- <br /> -- ------ <br /> Name " = // I------------------- --------- ------- ------- --- ---------------------Phone--- <br /> Address------ --- - ----------- <br /> - ; <br /> City---1 �Z-/74 ----------- Zip ------- <br /> ------------ <br /> Contractor's <br /> ------ <br /> _ __--- <br /> --=--------Contractor's Name--'-,4/:2. License #.r Phone <br /> Installaltion will serve: I.� Residences Apartment House.❑ Commercial ❑ 'Trailer Co rt ❑ <br /> +� 1 ' Motel Other---=---- ------------------------- <br /> ----- ber of bdrooms -- Garbage Grinder .--__bf livingnrts:--'-. Nur .__Lot Size-__. <br /> WateSupply. Pubic System <br /> and name - Private i <br /> } t Silt ----- --=_--- ---------------------------- ----------------------------------------- <br /> , .. r pth d an Adob Z _ 0 l , <br /> .L Characfer of soil to a depth of 3_f�eet:---Sand;�� Clay ❑- � Peat ❑ Sandy Loam � Clay Loam 0 . <br /> �.. ... . <br /> �• P ❑ ❑ Fill Material__ .' _If yes, tYPe--- - ---------=------ - <br /> i <br /> {Plot plan, showing si�fe af, lot, location of system ins relation to.wellls, buildings, etc. must be placed on reverse side.] <br /> E E. s � i <br /> NEW IN,STALLATION-WA(No septic tank or seep�_ge _.pit-permitted if public sewer is available within 200 feet,) � <br /> PACKAGE TREATMENTS ] 5E ICPT TANK'r['] Sizep <br /> _ - _____--- q i ' <br /> ----------- <br /> "C/S%Ei('_r 4 Capity/fG �—_;TySe -- - Material -------i-No. Corrlpartments._ -__ <br /> I 'DDistanr®e to-nst: 1r47e11.:..__ ! __-Foundation _;� --/-:---------Prap. Line--- ----------------------- <br /> V4.&�:, -- _: - <br /> LEACHING LINE, ( ] Na.-of Lire # j <br /> �- _ „Length of each line _____471��__- -_-_.Total Length.__._o� _. <br /> D' Box �� 1 � r i ---------f-- <br /> I /- Type Filter Material V-d/.Depth Filter Material________,i ___e� _ -- <br /> {. , <br /> l r Distance to nearest: Well-:--- _-_t_____-_____Foundation___ a ___-----__------------ Property LiOF <br /> ne_. <br /> SEEPAGE PIT [ ] Depth___ __________Diameter-----------------I---Number--- -------------- - Rock Filled Yes ❑ No <br /> Water Table Depth-----------------'' - -----------------Rock Size---------- ----------------------- ------------ <br /> Distance to nearest: Well----------------I------------( ------Foundation--,-------------.--- --_- Prop. Line--------------- <br /> ,- <br /> ----- ---- <br /> (Prev. --- Date----------- = 1 <br /> REPAIR/ADDITION Prev. Sanitation Permit#__________________ <br /> Septic Tank (Specify Requirements) - - --- --- ---- - - ------' q"----------------` ------ ----------------i-------------=- ---------- -------------------------------- <br /> F <br /> f <br /> Field (Specify Requirements)------- - i 3 <br /> , - - -_--__________________.____---_ --__________--------------------- <br /> Disposal <br /> I _ €�--------------- ----------- -------------------------------- ---------- --------------------- <br /> ------------------------------------------------------------------------- <br /> -- ----------------- ------ --------------- <br /> =(Drpw'existing and required addition on reverse side) ' t <br /> l 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 /> r � I <br /> "1 certify that in the performance of'the work for which this permit is issued, I shall not employ any person in such manner-as <br /> to becameessu'bj�ctt orkman' Compensation laws of�Calif orrria." <br /> Signed-IL 'G�.-'- '��� _..._ �_ . Owner t <br /> B ;---------------------'-=-- -----------------=--_--------- ---- -- Title <br /> -------„-- ------- --- --- -- <br /> (If-other than owner) ,. <br /> ” F R DEJRTMWt USE ONLY " j{ <br /> / �-fk i <br /> APPLICATION ACCEPTED BY - - --- -- -- <br /> ------------------- €--------------------------------=-- ------DATE --T ' ,--------------- <br /> DIVISION OF LAND NUMBER-------- ---------------------------- --=-- ------------ ..... <br /> --= =------------------ ---- ------------DATE---------- -------------- <br /> 1 <br /> ADDITIONAL COMMENTS------------------------ ------- -------- ---------- <br /> -------------------------- <br /> is <br /> -----=--------------------------------------- ------------ _ - <br /> ---- �-- t-- \ - t� -------'------ _ <br /> ---- -- - ---------------------- ------------ ---------------------------------------------------------- <br /> ---- ------------- ---- -------------- -- - ----------- <br /> Final Inspection-by .. =" ' - :="--Dater=` = <br /> EH 13 24 SAN JOAQLI LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />