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r FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .................. . y <br /> (Complete in Triplicate) Permit No. ....... ......... <br />'4 r Date lssued. .."I.. "�� <br /> . ... This Permit Expires 1 .Year From Date Issued <br /> Application is hereby.rimade`to.the'San Joaquin`Locdl_t�eaIfh Distdct'for a permit to.construct.and ins'tall'-the work rein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules a Regulation <br /> JOB ADDRESS/LOCATION............. '. -�/----- .._:..---GENS S TRA ........ <br /> Owner's Name., ....................Phone.-.__. ...._..----•--------- -------- <br /> .. ----- - :.....--------....... city........... .................. ........... ...---- ...... <br /> Address._.._-_.,.. .Phone--.f� _- <br />€ Contractor's Name___ License # <br /> Installation will serve: esidenceX Apartment House ❑ Commercial ❑ Trailer Court ❑ ,+ <br /> Motel ❑ Other ........................ /'_- <br /> fj 1 <br /> Number of living units: _:....1 _::..Number.of bedrooms-.11-3...Garbage Grinder..------....Lot Size.---/_�...1...�-/.;+�`--�-..-. - <br /> Water Supply: Public System and name_`__ .__.........� d Frivate ❑ <br /> ---•---•................ .......- <br /> Character of soil to a depth of 3 feet, J, Ci d ❑ Silt E] Clay ❑ Peat ❑ Sandy Loam E] Clay LoaM-r <br /> �. .__ <br /> Hardpan E] Adobe ❑ {Fill Mater.ial.... .- -. !f Yes, type---•------------------ -- - - <br /> I <br /> {Plot plan, showing size of lot, locat- <br /> ion of system in relation to wells, buildings,-etc. must be placed on reverse side.Y <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT [ 1; SEPTIC TANK I 1 " Size......./ ------ ----------Liquid Depth... ....... <br /> .. ents_.. <br /> ....... ..........CaPacitY -I .OQ...TYpa -.- - ... ate-vial.... ........:No. Compartm <br /> .^-t <br /> .. Distance to nearest: Well._------- l e �. _. <br /> .-..-Foundation ........Prop. Line_._S ............... <br /> LEACHING LINE [ ] of,Lines.:.:. (:...:Length of each Lina._.......--_---— Total Length .,..._:............... <br /> No: . <br /> it - <br /> 'D' Box�Ype Filter Material... .-.� _...-...Depth Filter Material-.- --' ................................. ..............t?j <br /> $ t <br /> Distancye•to nearest: Well.-/� t-------Foundation......`r�..-.Q--------------Property Line.---------.---- ------ <br /> SEEPAGE PIT [ 1 1 ��/1..1- <br /> .--Number------ ----- ------------------ Rock Filled Ye No <br /> Water Table De th-. .._............Rock Size...l__. .�- <br /> .m_�.—_�.•. -'r-'W <br /> Distance to nearesel'I`. Jn -I. - Foundation-------------------------.Prop. Line--------------....------.. <br /> h.�N <br /> f REPAIR/ADDITION (Prev. Sanitation Permit#---------------- .... <br /> -.----------Date.....--.--------------- <br /> ...) <br /> Septic Tank (Specify Requirements)............-------------- • •• --- ---- -----•-••---------•--L--- ------ --.....- <br /> Disposal Field (Specify Requirements).. ..........:....... • ..... ........----.... <br /> r , <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 /> i 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...... Owner <br /> .----------_...._Title---- --------- ------------------ ------------------------ <br /> .r <br /> (If other than owner) <br /> ICOR DEPARTMENT USE O Y <br /> APPLICATION ACCEPTED BY.......... - .DATE.. 1.�-7 --- ------- <br /> DIVISION OF LAND NUMBER .. DATE. <br /> ---- -------- -•.-------- <br /> ADDITIONAL. COMMENTS------------ ------------- ------------------------------------- ------------------------------------ ------------------------------------ -------- --------- --- <br />. -------------------------------------------------------------- -- -------------•------------- ------------------------------ •----------------------------------- <br /> ------------------- ----- -- ...­­­ <br /> - <br /> byi -- ----------- -------------- ----- ••- -� . Date-.01."� :� ....- <br /> EH 13 24 SAN JOAQUIN LOCAL HEAL ISTRICT F&S 21677 REV.7176 3M <br />