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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ' <br /> ------------------------------ - -- ------- --­_-------- .....7 <br /> (Complete in Triplicate) Permit No <br /> ---------------------------------- - - -------------- <br /> Date Issued---- <br /> ......................... <br /> ssued-..-.__........._..----_-...-..- ..................... 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 /> 6 <br /> r/ f]JOB ADDRESS/LOCATION f l .. �.....+�'' `L„ - ............ •--------- --CENSUS TRACT.......... ....... ........ .... <br /> Owner's Name._...__ 0 +1� tom_ . . ............ ............ ............-Phone..... ........ -•........... <br /> City <br /> Zip-------------___--- <br /> Address <br /> ---- - ------- . <br /> License Phone.....--------------------- <br /> Contractor's Name.. <br /> Installation will serve; Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---- ---- <br /> Number of living units:_ _....`-------Number of bedrooms- P_--:.Garbage-Grinder.......... Lot Size../-ORKA-_5.00 ------ ---•--- <br /> Water Supply: Public System and name--- .S ...............Private <br /> ❑ <br /> Character of soil to a depth of 3 feet; . Sand ❑4 Silt[❑ Clay ❑ Peat [:1Sandy Loam [_1Clay Loam El <br /> Hardpan ❑ Adobe ❑ Fill Material.. __..,.._ 1f.yes, type-------------------------- <br /> . , <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 /> f ------------ --Liquid De th---` ------ <br /> PACKAGE <br /> TREATMENT [ ] SEPTIC TANK [ ] } Size... yt(..1�� -��--k-•----- - q p <br /> t Capacity.. T e ." - MatewiaL ----No. Compartments.. <br /> { Yp '-~ <br /> Faundatian..-... . Pro f-----.---_.....-- <br /> Distance to nearest: Well ----- _ �� p' <br /> ii <br /> LEACHING LINE [ ] No. of Lines J .--_------------- Length of each line..T.P---*--------------To#al Length -� ZX--- ----.--- ...--. <br /> / - De th,Filter Material.. ... .. _ <br /> 'D' Box_ .. Type Filter Material.. :-�f� P f J --- - �- --- - -----•---• --------- -------- <br /> Distance to nearest: Wel!- Foundation------- ------=--- -------Property Line.....--------------........ <br /> - <br /> SEEff PFIT [ ] Depth ameter-�.3...--------Number......._ Rock Filled Yes No ❑ <br /> Water Table Depth-----------.... - Rock Size b�Z- - ---------------------- <br /> Distance to nearest: Well.------- - oundation------------------- --- Prop. Line.--...-.---------- -------- <br /> REPAIR/ADDITION ]Prev. Sanitation Permit#------- pate '.''.....:....... 1 <br /> Septic Tank (Specify Requirements)--------- ------------ --- -- - -- ------" <br /> [J /Q� <br /> tV_ -•--------------------------- <br /> Disposal Field (Specify Requirements)- ------------=---- ` ............ - � -; �-5--•-----,�y <br /> f!J" - D '---b----------------- ----- ---...- ----- <br /> --- <br /> - ... <br /> i -------------------- <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. Rome owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such spanner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed.. :----- - Owner <br /> ATitle ---- ----------•-- ................. <br /> By..---- <br /> (If other than owner) <br /> a FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ ........ ......... ....--- ----- <br /> .DATE .A.--;--.7?.. . .. .......... <br /> DIVISION OF LAND NUMBER ----------- - ---------- --------- - <br /> .DATE.. .... ............ <br /> ADDITIONAL COMMENTS--------------------------- ------- - ........ --- ----------- - <br /> .._.....__.. <br /> --------------- ------------------=--•------------------ .................. ...... .. ._ <br /> ..... <br /> . _.. .. _ __ -� .... - Date ... - - ....... .. :... <br /> Final Inspection b <br /> Pd5 21677 REV. 7176 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />