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- Ei•�[ Fq�% N � <br /> FOR OFFICE USE: <br /> L✓" _Y FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> {Complete in Triplicate} <br /> -------------------------- -------- -------------- - r'-•_ _ <br /> Date Issued. .;�1'�"D <br /> -------------------------------------- This Permit Exjii es 1 Y ar From Date Issued r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> I This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIQN.__- � --------------- J - --- ------ •--.. ----- ----- ---- ---- <br /> --L� -- - ---------- ------ - CENSUS TRACT------ E <br /> Gvsi_ ' <br /> ' 1 - <br /> Owner's Name ------ `}�o-- -:-�--- -�-- ----- <br /> --------- <br /> � - Phone----' -------------------- ----- � <br /> fry f::.._....�. - <br /> Address- ---------- ----------- -=- - -J�-- - <br /> ._.city--------- ---------------------- -------------Zip------------------------------- <br /> ------' y <br /> �r License #. t� _rf'1---Phone ----- <br /> Contractor s Name- - - ` <br /> lnstaliatian_will serve: Residence . partment House.❑ Commercial ❑ Trailer Court. ❑ t N <br /> E' )..Motel -Other . .. , <br /> ❑ _ ._ <br /> --Garbage Grinder Lot Size /�--/S '--! <br /> 4 Number of,living units:__._.____._�__Number,;of l�drooms:---__ � �- <br /> System- " e -----------------------------_._.:; ---------------------------------Private`7 <br /> it to a depth o nd.name(and <br /> day ❑ . ❑ y.L ❑... _ y ❑ <br /> W ter Supply:so Public � �- � Si Cla Peat Sand Loam 'Clay Loam <br /> e <br /> Character o p f 3 feet: <br /> _ <br /> ± Hardpan ❑ Adobe Fill Material_ -----If yes, type------------.------------------- <br /> {Plot plan, showing size of lot, location of system in relation to,wells, buildings,'etc. nlust be;placed on reverse side.) <br /> t }, <br /> NEW INSTALLATION: [No "septic tank'or seepage .pit permitted if public sewer is available within 200 feet,] <br /> . <br /> TREATMENT- [ ] ,, <br /> SEPTIC TANK •j`]- - Size - - --- Liquid Depth <br /> PACKAGE <br /> s <br /> i -'== =T a Material---=----------- --=--:_-_No. Compartments.-=--------=- ----.---"----------- <br /> { ± Capacity..:: ------'Type---•---=--------------- <br /> I .,: . . :. ._ 'Distance to nearest: Well ---- -------- ---------Foundation--'--------.-_-,.-----=_..Prop. Line = <br /> LEACHING LINE, ['] Na, of LinesLength of each line._ ---.Total Length <br /> --------------- <br /> ---------- <br /> Box---------` Type Filter Material f'_- ---':Depth Filter Material -" --------------------- <br /> D' <br /> t Distarnce,to nearest: Well--------------- :---- Foundation--------- ---------------_.._Property Line----------------------------------- <br /> SEEPAGE PIT ( ] p. __ Rock Filled Yes No <br /> De th-----`:----- ': D.iameter--------=-----------Number---------------------------- ❑ ❑ <br /> s : ' Water Table.Depth---------------- °-------------------------------------- Rock`Size t <br /> I Distance.to nearest:Well�...__-__._.___'-- ---------- --_- - ; . ----.Prop. Line------------- - -- ----- - <br /> .. <br /> REPAIR/ADDITION (Prev,,Sanitation Permit#._•----------------- --.-------•-------- --'--.Date-----'_--------------.-----:------=------------ <br /> Tank (Specify Requirements) __ = = --- ---------------- <br /> Septic1 - - - <br /> i Disposal Field(Specify Requirements)`------ -. — - 1- �/`� -�- --- ----- ------ <br /> ' :- J <br /> _ r _ <br /> - <br /> - <br /> t --------------- ---- - ----------- ^ - - <br /> s <br /> (Draw existing ana 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 /> 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 manner as <br /> to become. subject to Workman's. Compensation laws of California." .. <br /> Signed" - _ =�: : . .. <br /> f <br /> By- ""I ------ --- <br /> - (lf other than owner] <br /> I f DE RTMEWUS NLY <br /> APPLICATION ACCEPTED -- ------ ------ ------ ------ -------- -------- -------DATE,--- - ------------------ <br /> .'Z 7 <br /> E DIVISION OF LAND NUMBER----- ----------- ---- ------ -----:. DATE . <br /> -------------- <br /> ADDITIONALCOMMENTS------'------ ----- -----------=------------------------------------------------- --------=------------ <br /> Ii --- -------------------- ------- ---------- ------- ---------------------------- ----------------- ---- -------------- _ ------- <br /> -------------==---=-----=-------------=------- -------------------- -- <br /> e <br /> i - --=----------------- ------- ------------------------ ------------------------------ <br /> --------------------------- -------- - <br /> ---- ---."- -----__. _.__._ <br /> I - ----` Date """ <br /> - ---- --- --- <br /> Final Inspection,b ---- � cn_ .� ... � -�-�---�'---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT " F&S 21677 REV. 7/76 3M <br />