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FOR OFFICE USE: FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) '� Permit No..._..._.'_ ._._.___. <br /> ---------------------- ---- --- ------------------------ <br /> -_ <br /> ----------------- oF� .� � <br /> � L / x`3;;1 . Date Issued,S'-_Z-�-�---- <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 /> #�3<( 1- 12 lrA-tre t <br /> JOB ADDRESS/LOCATION--------------------------------------------------------------- ---------------------- ---- ---CENSUS TRACT..----- ---•------------------- <br /> C' 7 j qe!?' � ._ 83sYa2 -------------- <br /> ------------ <br /> .2 <br /> Owner's Name ------ -- Phone <br /> 1 <br /> ` Address----------------�- -----------------------------------------c (-fC {1 ---- --------------- --------Cit Zi <br /> 3Y--------- --------------------- -- Pg�------------------------ <br /> ['rAR� I� 9,g 3 GSA. <br /> Contractors Name----- ------ -- -- - = --------------------License # - Phone. ------------------------------ <br /> Installation <br /> ------- ------------- -- <br /> Installation will serve: { ? t Residence �. Apartment House E] Commercial E] Trailer Court. Elt <br /> . <br /> S 1 ' <br /> t i.......� �... Motel ❑ Other.---------'------------------ ------ <br /> Number of living-units --i-Number of. bedrooms_..___-__Gar.bage Grinder------------Lot Size_______ ___� Z'____._.__._r 1�-' _-____._______._.__-_._. <br /> Water Supply, Public System and n ---------- <br /> ame ------------------------------------- ------------------ --------- ------- --- ------ ------- -- -- - ----Private <br /> -- <br /> Character of soil to a depth of 1feet: Sand [W Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam E] x { <br /> 'Hardpan ❑ _ Adobe ❑ Fill Material-------------If yes, type------------ <br /> a (Plot plan, showing size 'of lot, location of system in relation to wells, buildings,`etc. must be plpced on reverse side.) <br /> } � r i f <br /> NEW INSTALLATION: " (Na _sepep tic tank or seepage pit permitted if public sewer is available within 200 <br /> --- _.. <br /> r <br /> feet,) <br /> PACKAGE TREATMENT' [ '1' r SEPTIC TANK Size � - --Liquid Depth <br /> T MeiaCa aciype -_ No`: Compartments- =----- <br /> � -------•--------------- <br /> W <br /> __ ;Distance R _ Z <br /> i�twhearest. Well - ---FoundationProp. Line------ ........----------I <br /> ' <br /> LEACHING LINE_ [ } No. of Lines- ------------ -------- ----- Length. <br /> f each line_._-_ Q______._ ---.Total,Len th ---------------------------------------- <br /> D' <br /> ..__ - ?, .-- 4-- <br /> D' Box!_: -Type Filter Matenal---- f�'x'___!__.Depth Filter.Mater ial--I....... _T--------------------------------------------------- <br /> 3 )j / . <br /> -Distan e.to nearest: Well._.._1_.p�_j_____/-F undation_______�0-________,__.Property Line-----------------___________________ <br /> SEEPAGE PIT Depth-- Nurriber__.____-� - -_ <br /> € ] p - - --------------- Rock Filled _Yes ❑ No ❑ <br /> d-Rock Size-- ----------- <br /> Water Table De th ----------------------------- <br /> lame Diameter <br /> Distance to nearest: Well------------- ------------- ----._Foundation--------- .--- -_.Prop. Line------------------------.--_. <br /> k - i <br /> REPAIR/ADDITION (Prev:Sanitation Permi't#_-:______________ _._________. __-__:_____,Date.__._________.__--_._____.__.'._________:_____} <br /> SepticTank (Specify Requiremenfial = -------------------------------- =-------=---------------=-- ------------ -------------------------- - -------.------- -- ----- ---- <br /> - --- - <br /> Disposal Field (Specify Requirements}:----------- �� �--- -- -------=------•---------------------------------------------------------------- ---- --------- --- <br /> • <br /> ------!---------- --- <br /> =--------------------------------- =-- --- :- -------- - - -- ----- ------------------------------------------------------- --- ------ ---- -------------------------------------- ---------------- <br /> ( _�w existing and equ--' " addition•on reverse side) <br /> 1 hereby certify thatl have prepared this application and 4hat the :work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and! Regula?ons Fof fhe San Joaquin Local Health District. Home owner or licensed agents <br /> i signature certifies the following: IIE <br /> "•1 certify that in the performance of the work-fir which this-permit is issued, I all not employ any person in such_ manner as <br /> to become subject to Workman's Compenscitiori laws of California." <br /> Signed ------: ------------------- - --Owner <br /> B .. -. ------h..J ._Title------- <br /> k y - ------- --------- <br /> o <br /> - - - <br /> (If '6th' than owner} # <br /> t 3'PCIADEPARTMEW tJ ONLY w. <br /> APPLICATION ACCEPTED BY--------I .. ..; .. :. -DATE.'------- <br /> --- <br /> DIVISION OF LAND NUMBER:--- '=------------------ --------- --- DATE-------- -- <br /> - -------------- - -------- --- - } <br /> ADDITIONAL COMMENTS-----------L•------------------- <br /> ------------------------------------------------- _ - <br /> --------------------- <br /> - <br /> ----------------------------------------------------------- ---------- -- -------------._._.__---------------- ------------ <br /> -- --- - <br /> ---- -` <br /> --------------------- ------------ ------= - ---------------------------- <br /> F Final Inspection-by:_.___.._:_:- _ --------------------------------------' — �- - '" ` <br /> _�__------------------- ---"'� ----- ------------------------ -.Date � - --- ---- <br /> EF1 U 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 21677 <br />