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J_ <br /> 13 <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------- ------------------------- <br /> ;�; (Complete in Triplicate) Permit No.7 -_2170___ <br /> ----------------------- ---------------- --- . <br /> Date Issued_,-//--,-_$- <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 /> JOB ADDRESS/LOCA , l 4.0 d -- `r ---- <br /> - p-- -- -------- -- ------CENSUS TRACT----------------------- ------ - <br /> a r_ <br /> Owner's Name P.h�one— -- -------------------- <br /> ac--- -- ---- city- -- <br /> Zip----------- ---- ------ <br /> Contractor's Name---------- <br /> -------_License #___ 2�'�'�_ Phone ___ <br /> (` - <br /> Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--------------------------- ----- ---------- <br /> Number of living units:----_E -------Number of bedrooms___..----Garbage Grinder_ Lot Size------�. _____`f" ``T' <br /> Water Supply: Public System and name ------------ ------------------------------------------------- -------------- ---------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand E-] Silt E] Clay E] Peat[:] Sandy Loam E] 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 see age pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK (/ Size_ --------------------------------------------Liquid Depth -_-_-_--__-__-______- <br /> Capacity--- - - -----Type_- °-+'_ Material_ 't�-=----- _No. Compartments--------- <br /> to nearest: Well-_______.S�-_ ��______--_____FoundationQ _ Prop. Line__ _ <br /> LEACHING LINE [411 No. of Lines------ 5---------------- Length of each line._____9 -------Total Length ------------ <br /> /11 <br /> D' Box_-!--:-----Type Filter Material--__ Depth Filter Material -______/�l___-.-------------------------------------------- <br /> Distance to nearest: Well----- - -Foundation-___ '' _/ ____Property Line_____ _______. D <br /> SEEPAGE PIT [ ] Depth 1ameter---X ..3 "` �. - Rock Filled Yes �No <br /> "'---Number -- - -- ----- - �� �.? ------------------- <br /> Distance <br /> //--- -- --- - ❑ <br /> Water Table Depth__________/a-e__ --_______--_______.Rock Size--- <br /> __ ______, __3 <br /> Distance to nearest: Well____ __ -----------------Foundation---/ .____.Prop. Line___T------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------________----_------------------.Date_______-__---________-_________-__----) <br /> SepticTank (Specify Requirements)------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> DisposalField (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 /> signature certifies the following: <br /> "1 certify that in the performancelof t e work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workpran's mpensatioa"lbws of California." <br /> r ,, <br /> Signed - -/ `� ---------------------Ownerj <br /> gg ^a1 +---------" C ,° "" 77 <br /> --~ Title L`C <br /> Y --- -------- ------ ------- ---- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY___ v __ - DATE _---__ ___-__ <br /> DIVISION OF LAND NUMBER.--------------------- --- --- -- -DATE--------------------------------------------- <br /> ADDITIONALCOMMENTS--------------------- -------------------------------- ----------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------ -- -------------------- - ---- - - - - <br /> ---- -- ---- <br /> -------------- - - -- - <br /> Final Inspection by:---. ---- Gz ---------Date. ? <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 216» REV. 7nb 3M <br />