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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------ ----------------------------- <br /> (Complete in Triplicate) Permit No. �_ / <br /> ------------ -------- <br /> -- - - -- - - - <br /> ��( - - Date <br /> - ---- - ----- <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/LOCATIO - -------- -- ---------------- CENSUS TRACT <br /> Owner's Name. " -I ----- ------------ ho ------------ -------- ---------- <br /> Phone <br /> -;- -----------Y-.r.,�C---------;-- _ - d - -- --- city--- ------------------- --Zip ------Address -- / - , <br /> Contractor's Name___-___- <br /> ," -License _Phone 3 <br /> -�. <br /> Installation.will serve: Residence [ Apartment House E] Commercial ❑ -Trailer Court E] F <br /> t Motel ❑ Other_ <br /> Number of living units_____________ __Number,of.bedrooms-_-__;3__Garbage Grinder------------Lot.Size ____-_____-___._____._ <br /> Water.Supply: Public System and name------------------------:------------------ ------------------------------------------------------ --- -_:-`---.---- ------Private [� <br /> t <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ®.' ' <br /> a Hardpan❑ Adobe.❑ Fill Material._-_---__.__If yes, type_. ____-______._ <br /> (Plot plan, showing size`of.lot,,location'of. system An relation to wells, buildings,'etc. must be placed on reverse side.) <br /> . No.f t ; seepage pit permitted if public sewer is available within 200 feet,) ; <br /> PA KAGE TREATMENT— [ SEPTIC TANK. Size- ----------x ------x----- --------Liquid Depth --- ------------ <br /> f Capacity--1, _¢______7Y.pe _ Material No: Compartments --------------- <br /> A ' <br /> ---- -----Distance to nearest: Well—, Foundation-----V__X ---------Prop.1Line-_-. � t _______________�I <br /> LEACHING LINE` [K Na. of Lines,----: ---------------.-:Length•of each lin&.:.:-....... -- --i- TotaE' Length ----- - "Q--------------------- <br /> -------- I <br /> D' Box--_-.)......Type Filter Material--------�..+'__-1---Depth Filter Material------_---�:- - .- ---_-_----------------1___- --------- a <br /> ' Distance to nearest: Well-, ?"G? ':_ -Foundation . Property- Line---_____ ______ <br /> r <br /> SEEPAGE PIT [ Depth__ ' _ . - Diameter .___ __. , �. t11—k-3 Rock Filled Yes ENo ❑4p <br /> Ie De :th Q _ Number = Rock Size / -- P <br /> _._ <br /> j ., t ------------- <br /> Water i s , <br /> c <br /> F Distance.to nearest: Well----._- ?---------------- ---------------..Fouhdati on -- - -----------Prop. Line-_-.-----------.-------- -- I <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------- - ------------- -------:Date---------:---------------------------------------) <br /> Septic Tank (Specify Requirements)-------=----------- ----- ---=-------------------------------------------------------- <br /> Disposal Field (Specify.Requirements)---------- -------- - ------------------------------------------------------------------------- ------------------------------ -----------•-------- <br /> 1 <br /> ----------- <br /> _----------------------- <br /> _______________________________-_.____-_____--- ------- __ __--_______________-__-________________ __- __________ ---___.______.___r <br /> ---------------------------------- <br /> "------ _ _ - ____-______________________________-_____-___________ - <br /> (Draw existing and required addition on reverse side) w <br /> I hereby certify that I have prepared this application and that'the -work will be done in accordance with San Joaquin County 1 <br /> Ordinances, State Laws; and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licensed agents i <br /> signature Certifies the following: <br /> "I certify that in the performance of'th6':Work"for which this'permit is issued, .l shall not employ any person in such 'manner as <br /> to become subject.to..Workman's. Com cation law California." } <br /> Sig <br /> ned ---' ` --- --- -- ------0- Owner <br /> By-{ <br /> { <br /> 1 <br /> ;Title <br /> '(If&Kir thdri"owrier[ <br /> j FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- - - ----------- - ------------------------------DATE ---- > " _;2.7- -- -3 <br /> DIVISION OF LAND NUMBER -.:_-. DATE. = <br /> ADDITIONALCOMMENTS------- ------------------------------------------ ------------------ ----------------------- ---------------------------------- -------- ----- <br /> I ----------------- -------------------------- --------- -- <br /> -------- <br /> Y--- <br /> ��� _ ----- ------ <br /> -------------------------------- <br /> Final ins ectio`n- -� f <br /> - = --- --- - Date 1 <br /> --------------------- - Q' <br /> EH 13 24 SAN JOAQUIN LOC L HEALTH DISTRICT F&5 21577 REV. 7/7G 3M <br />