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F : FOR OFFIC" USk: <br /> OR OFFICE USE <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) �.....- <br /> . ""-..-..-- Permit Na'"__--- "------ <br /> ............................ ... . ...... ........... . <br /> Date Issued."_5-�'(�---' <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 o. 549 an existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION­ �J ..CENSUS TRACT_--------------------------- <br /> ESS/LOCATION..-..../ .. $._ 41 /� <br /> Owner's Name.... .. . ............. . .. ...... - ---....-...... .Phone.2._�,X q. ..... ... <br /> ...Cit ZiP.9Z7:4�............ <br /> . <br /> Address_------ /jl O?lJ ' _,-- ... ... y <br /> Contractor's Name....................�� ------� - . ------- --......License #- �.3 >'hone..� <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel (] Other......... ...... --- ----- <br /> _.. <br /> Number of living units:....../ _.Number of bedrooms....,�...G�ajr ...Lot Size..--6�_- <br /> ..Garbage Grinder......... � /.�a---=- -�--- - ��- -. <br /> Water Supply: Public System and name-- - - ------------ _._ Private El <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 within 200 feet,) <br /> +' PACKAGE TREATMENT [ } SEPTIC TANKSize ... 5.. _ _ ----vo <br /> . --Liquid Depth <br /> ."- .- <br /> Capacity /+ dv ...Typ .�� �' �Material No. Compartments. ! " <br /> Distance to nearest: Well.--- Foundation../40 . .... <br /> .... <br /> ._.Prop. Line.... .................. <br /> k LEACHING LINE [ No. of Lines - _..�... Length of each line,---�0------------------ Total Length . . ..." <br /> D' 13ox.417".' . Type Filter Material` go <br /> OCo .Depth Filter Material._... ------------------------- <br /> Distance to nearest: Well... --- Foundation._. Line--..-,. <br /> -----•---------Property ' <br /> .Diameter._."3.3......--- Number_.__... P( Rack Filled Ye No <br /> SEEPAGE PIT Depth...a <br /> 9 ! Rock Size.__ - 1 <br /> Water Table Depth ------------ --- -----------------� •- �. � ...-----�------•----------- � <br /> Distance to nearest: Well.---.-� ..-. ........Foundation... <br /> Prop. Line._.. . ..... ........ <br /> REPAIR/ADDITION [Prev. Sanitation Permit#--------........ ----- -------- -------- ------Date. .------.------.---.....-- --- ------ <br /> Septic Tank (Specify Requirements)------ -------------------------- <br /> Disposal Field (Specify Requirements). ___ ---------------- - ------------ " <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 San Joaquin Local Health District. Home owner or licensed agents <br /> r <br /> signature certifies the f6IIiiW1-r g.- - <br /> "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner as <br /> to become subject or an s pens tion laws of California." <br /> i Signed---- - ---- - -- - .-�-k ... - --�- .----i-------- <br /> Owner <br /> -.... Title.--- �- - ....................... ........ <br /> By-------- - --------------- ... / ,.. <br /> (If other t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- --------- -------_ .......................DATE ... �� � 7��..... . <br /> ' DIVISION OF LAND NUMBER....----- ..............-.DATE.-_...-_......... --.... <br /> ADDITIONAL COMMENTS_—_. . ........... f-------- --- - ----- ----------------- ....-- <br /> ------------•--------------- ---- ----------- <br /> --- ------------ -------- ------ <br /> Final Inspecflon b Date...- �?. -- '.� .. <br /> Y----- '__ - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ra�§2y <br /> . 7/76 3M <br />