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FOR OFFICE USE: � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <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. 544 and existing Rules and Regulations; <br /> JOB ADDRESS/LOCATI 3 el I �/ / <br /> .G�- -:.,z 1__` CENSUS TRACT <br /> Owner's Name2[[ r _ [,F - <br /> `- <br /> - Phone <br /> Address-- c` <br /> ----- City . - -- - <br /> f <br /> _ . <br /> Contractor's Name___ <br /> __..License #_ 7 _. Phone <br /> Installation will serve: Residence Apartment House ❑ Commercial F-1Trailer Court ❑ <br /> Motel ❑ Other --------- <br /> Number of living units_ ____ ________Number of bedrooms:__-'.----Garbage Grinder ------- __Lot Size_.._ °�t � <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 Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. _ <br /> - 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.) "t <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT ] ] SEPTIC TANK _ <br /> Size `�' - _ - - Liquid Depth - `. <br /> Capacity- <br /> rial - l <br /> ----- __A Mates . No. Compartments. . ' -- <br /> Distance to nearest: Well Foundation. -----... Prop. 1� <br /> fa _ Line--/r ------ *, <br /> LEACHING LINE ( Na, of Lines .---.Length of each line----- " ------ - -_-Total Length ,/14' <br /> D' Box/.--_'/Type Filter Material_ '---�-depth Filter Material_------,: <br /> Distanceto nearest: Well..._ {. ----- ---__Foundation-_2715_ --Property Line A-- r <br /> SEEPAGE PITr �� <br /> [ }� Depth.. 3Diameter_. r -- Number------ -_ ------ Rock Filled Yeses No ❑ <br /> Water Table Depth--- ---'9 -- - ---------- R <br /> ack Size <br /> Distance to nearest: Well__.!'e'' <br /> REPAIR/ADDITION (Prev. Sanitation Permit# ------ ------- _- '� <br /> ----- Foundation ---�--�--- -.---- .Prop. Line_-�-"--- <br /> ... --------- <br /> -_- . - Date_- } <br /> Septic Tank (Specify Requirements)___ _______ ____ <br /> - - - -------- <br /> Disposal Field {Specify Requirements}_ ------ -- -- - ----- <br /> ----- -- -- ----- --- ---------- ------- --- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 W rkman's mpensation laws of California." <br /> Signed.. __ _ <br /> - -� - — -- ----- Owner _ <br /> By__-- -.- - - le <br /> ]If other than owner] -- <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- <br /> DATE ---- -� <br /> DIVISION OF LAND NUMBER... <br /> DATE <br /> AL COMMENTS------ -- ------ - <br /> ----- ----- <br /> ---------------------------- -- <br /> Final Inspection b �' <br /> P Y S� <br /> - - --- --------------------------- --- --Date �f! <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV, 7176 3M <br />