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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> = ---------------------------------------------- <br /> (Complete in Triplicate) Permit No.-. <br /> --- <br /> '0 bateIssued..t_4r-_.=._.._ _. <br /> -------- f -�- This Permit Expires 1 Year From Date Issues! <br /> Application is hereby made to the San Joaquin Local Hepith 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 Mules and Regulations: <br /> JOB ADDRESS/LOCATION.----------'-- -_ ----- ...CENSUS CENSUS TRACT- -------------------------.--------- - • <br /> Owner's -. <br /> Name------------- - r# <br /> ,/ -- -'�-- -�,/�-�---=---- -- -------------=----- ----- ----------------- _ -------Phone <br /> � T = <br /> Address--- C = `- - F Cit =_5`a" <br /> _ P--------- <br /> a --- ; ---------yy--------- Y..�._.._a� �-� ------ ------- Zi <br /> Contractor's Name-- ---- /C _ --=-- -- ------------ ice �Phone_ <br /> Lnse # - �� <br /> « J - ! <br /> Installation will serve: Residences Apartment House❑'�, - ornmercial ❑—Trailer,Court ❑ I <br /> Motel ❑ -' Other---.---,` <br /> --------'------- <br /> Number of livind units:..r_-_._ --------Number'of. bedrooms"_ ..-Garbage+Grinder___._1_r; LotaSize_._.11 <br /> Water Supply: Public System and name__ -_ �'� � '' Private ❑ i' <br /> t <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy-Loam ❑ Clay Loam " -- <br /> Hardpan 0 ' Adok;e ❑ Fill Material___-------�.If yes, type----- <br /> ___----------_------ i l <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 seepage pit permitted ifpublicsewer is available within 200 feet,] <br /> PACKAGE TREATMENT _T <br /> [ ] SEPTIC TANK ['] Size.--.__-.- __0 (" - _ Liquid Depth -_C _ __ <br /> N Ca acit __ . f <br /> P Y P J+^ 1o. Compartments <br /> Distance to Weare t: Well..-..-Ie ------------------ Fou ndation__`__fe.�_.-._..._Prop, Line.-_��O_-____-------- <br /> LEACHING <br /> _._-_ _LEACHING LINE [ ] No. of Lines'j-..-17-.. ,.____Len Length of each line ` ---- <br /> g =- --��� -- --:.Total Length,------------. �-�_=-�-- <br /> v fes -- <br /> 'D' Box___ Type Filter Material_ '__./ epth Filfer Material__-------- ---------------------------{ <br /> : a `._ - ---. ro erty Line.. <br /> __-_'Dist _ --._ -'_..._ -- ---------------- ___ ....❑____..__No_ <br /> SEEPAGE ❑T Diameter . _ _Number________ - -_ Rock Filled YesDep <br /> th <br /> t <br /> Water Table'Depth--------------------------------------- ------------- ----Rock Size -' -- - <br /> Distance to nearest: Well--- - .-_---- --- ------- ndation "_ _____.Prop. Line,._ <br /> Date- <br /> " REPAIR/ADDITION[-Prey. Sanitation Permit#�___---_------------------_____________ ----------------- <br /> Se <br /> } r <br /> ------------------------------- <br /> Septic Tank (Specify Requirements)----- --- <br /> -------------------------------------_ = <br /> ' -------- -- ------- -- �-- ---------------- <br /> $ <br /> Disposal Field [Specify Requirements]______________________ _____________-----=-----� -----------------#'. <br /> t i <br /> —-- ----------------------------- <br /> ----------'---- �--4-- -' <br /> .aF_Irx ._._. __ <br /> [Drava existing and required addition onjreverse 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 Regulations4f the San Joaquin Local Health District. Home owner or licensed agents l <br /> signature certifies the following: i , ,�4 a .f # <br /> "I certify"that in the 'ci � <br /> performcince•of t�work:fo which this perniit�is issued; 1 shall'not employ any person in such manner as <br /> to become subject to Workman's Compensation- laws of California:" ,! <br /> Signed-- -- �--- ---------;-------- � ����- `--- ---e <br /> _ ; <br /> BY ✓ ✓'�' _�!-t ------------- ------ --�.`Title !'.w>': -�'�......-------------------------- <br /> [I other than'owner) ; . <br /> 'FOR'DEPARTMENT USE ONLY" t <br /> APPLICATION ACCEPTED BY- ----- == :' -u-,„. - <br /> DATEdrl <br /> - — � --------- - <br /> DIVISION OF LAND NUMBER ------=-`'-- --------- ' . ----DATE'S"'�. ^" <br /> 7 <br /> ------- ---------- ` <br /> ADDITIONALCOMMENTS_--------------------------------- -------------- ------------------------------------------------------------------------------------`=------ �- <br /> ------------------------=-----------=- ---------------- ---------------------- ---------------=----I--------------------------------------- ---------------- <br /> ______________ ----.--_.----_.-._.__._ ------------- <br /> .-._______.____.___..._....�_________-_____.____.__.___..__.._.._-_ __..-_.__________-______________-_____.___-___-____-___.._.-_.___-___--___-___._________.___ .. <br /> _________________________________'_____________________-._________________ ____-------- __.__________________-_.._-._.___.-.___..___.__._.__.____._-__.___-_._ _.__.. ____..___._.-.___.._-__._ <br /> EHnal13 24nspection bY.......-----------��'l SAN JOAQUI-- OCAL HEALTH D:ISTRICT---+---�.. . Date.- 3"-��s s3 ------------X76--- <br /> 577 REV. 7 3M <br />