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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT c� <br /> ---------- ----------- - <br /> °--- ---- ------------------------ `v <br /> ' �w !;*(Complete in Triplicate) Permit No.._7 7 :1._ _ <br /> ------- ------------------------- --------------------- a _ <br /> Date Issued--- }'� ---� 7 <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 Ordinan e No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION._.., a .__.CENSUS TRACT=_______________ ' <br /> l , <br /> Owner's Name - " - ------= Phone. ---. .j�� <br /> Address------ Cit Zi <br /> ---- ---- - Y-- ------------------------------ <br /> ConName-=-- ' ----:-- ------ -----License #_, ?1.�3 ------Phone-._ <br /> _ L�' <br /> Installation willserve: ? Residence Apartment House ❑ -Commercial ❑ ;Trailer Court ❑ <br /> ; Motel•Q -+Other:----------- <br /> ---------- - r <br /> Number ofJiving units:-----/-.-_ Number of bedrooms. �_ Garbage Grind Lot'Siie----- -----------____------------------ <br /> x <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 Loom ❑ <br /> 'Hardpan ❑ Adobe [+ Fill Material-- ---If yes, type--.-.-----_-_--__._--_ <br /> (PlotIan, showing size of lot, location of s stem in relation to wells, buildings, etc. must be laced on reverse side. r <br /> P g Y 9 P , <br /> NEW INSTALLATION: INo�`s'eptic tank or seepage pit permitted if public sewer is available within 200 feet,} i <br /> PACKAGE . ... - <br /> TREATMENT [..]..}.SEPTIC TANK Size -- __-- --'-- _ _-- _-_- -------- 'Liquid Depth- - _ - ' <br /> .. ••• Ca licit Material __ No. Compartments { <br /> P, Y---------------- -TYPQ_._ =-- ---- P ---N <br /> Distance to nearest:.Well--------------------- ---------Foundation----------------------;__.Prop. Line----------------------- -f. <br /> LEACHING LINE I1_- No. of Lines'_:-_- :-- `_----_i._ -.Len th_of each line.-_----.--.--------- ------Total Length.-------'------------------------- ±-- I <br /> 9 <br /> 'D' Box._:_.___ ___Type Filter Materia!_ __.___Depth_Filter Material_______.__. _ ______ _________ ____.-__._--_. <br /> . : . . -: - <br /> V <br /> : 'Distanceto;nearest: Well---------------"-.-__._-__._Foundation-----------:-----.'--------Property Line---------------- --------f- <br /> ---. <br /> SEEPAGE PIT Depth--- --- - --Diameter _ -'--'----____--.Number------____ --- -- ------ ! Rock <br /> Filled Yes ❑ No ❑ <br /> Water Table`Depth----------------------------------------------------- .Rock Size <br /> Distance.td 'nearest: Well------------------------------ -----Foundation- .--------------'------__:Prop, Line ------------------ -------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-- --------------------- ------------------r Date----.---------------_'_' _ <br /> Septic Tank (Specify Requirements) 1 :---- - -- ----------= ----` --:--- i <br /> Disposal Field (Specify Requirements)---- " ------ - -- ----- - -- ---- -- - -------------------- -- <br /> /. t.� C�� <br /> Q_� - --------------- <br /> (Draw existing and required ` <br /> q red addition:on reverse side)' <br /> 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 „ <br /> ''the' Sari Joaquin Local Health District. Home owner or licensed agents <br /> w t. <br /> signature certifies the following: <br /> "I certify that in the performance of the work far which this 'permit is issued,'.I shall not employ any'person in such manner as <br /> to become s ct to Wor n's mpensation..laws of California.',... ; <br /> Signed-- -- ------`-- ----- <br /> -- --------- Owner ; <br /> BY Q fr%� -- :Title ------------------------------------------- ---- # <br /> - <br /> owner) # <br /> 1• (If other than FOR DEPARTMENT USE ONLY' <br /> ACCEPTEb BY' =........... --------------------_. DATE -------------- <br /> APPLICATION <br /> DIVISION OF LAND NUMBER. = = ' " --- DATE--------=---------- --- ' <br /> .,. <br /> ADDITIONAL COMMENTS--------------------------------------------------------------------------------------- -------------------- ------------=--------------------------------- <br /> .,, --- <br /> Q <br /> -----`------------------------------------------------------------------ -- ------------------------------- ---------------------------_-------_---------_---------------------------------------------------- <br /> -------------------_-------------------___.__ --- ---------- - -------------------------------`-----"`--------------------_------------_---------------- <br /> I <br /> ----'-----------'- <br /> Final Inspection'by:__.__ -_. 2 - ---- __-------------------------------------------------------------------- <br /> r <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M <br />