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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT---------------- ------ C ' <br /> 5' <br /> -----•- Permit No .-. ...'" <br /> (Complete in Triplicate] <br /> ---•----•--•--------------• --- ...----- --.----.....---- f <br /> Date Issued..` �`-� <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> I <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/LOCATpION....-.fit' _ -... CIfIS! �C/�-... -�4-------- ...-..CENSUS TRACT_.... <br /> Owner's Name........JLr.:. - Phone _ i <br /> t . . . .. <br /> Address. •�' = ----- . ---.. ..---- City...-. !'c' zip.. :.- <br /> Contractor's Name.......-- ................�License #...�i:S�I C --- .Phone.- -- -- '---• <br /> Installation will serve: j Residenc Motel`s Other;_ ❑-- ' Commercial E] Trailer Court E]"'•.Apar#meat.House <br /> Number of living units:._.(..---------Number of bedrooms-o2— Garbage Grinder/140...Lot Size.. X �] - •---.--- 5 <br /> �J r' ....------------------- - <br /> Water Supply: Public System and.name ---------------------------------- -- Privet <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay"❑ Peat ❑ Sandy Loarnr 4 Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material_. .... ....If yes, type... -------_--------- <br /> (Plot <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 if public sewer is available within 200tfeet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [' 1 Size...................----------------------------------------Liquid Depth.- -------- <br /> Capacity <br /> ------ <br /> Ca acitY... ..x..-----TYpe--------------- -- - Material-------- --------•-"--•- ._No. Compartments.... ------- ---- <br /> .� <br /> - -------- <br /> Distance to nearest: Well--- ------------- - -- - ------ ---------Foundationet_...... -- . ..-- .Prop. Line....--- <br /> LEACHING LINE [ ] No. of Lines ------------------Length of each line --------- ---- r Otal Length .....---------------- .......... <br /> S. .. <br /> 'D' Box----: ......Type Filter Material....................Depth�Filter Material. ................--.---------------------------. ---••-- �> <br /> Distance to nearest: Well----------------------------Founda,,tiioon------------..---------:----Property Line-:,!I----•----.-------------....... <br /> 11 - �.. <br /> SEEPAGE PIT { 1 Depth..__..._.....-Diameter--------------------Number-----------•--- ---------------- Rock Filled Yes ❑ No <br /> T Water TablesDepth---------------- ;� y_..:.-�Rock Size...--- -- <br /> .......... .... ...... .----Foundation.. - 'Prap. hne' -• <br /> { <br /> REPAIR/ADDITION (Prey San+taction Pee to amit#---e .....- .�.f-------------- --- F --Date-- -- -.-- ----. .....-- --- - } <br /> Septic Tank (Specify jq irements) /7 Q :'_ _...,��J <br /> DispWo <br /> eld (Specify Requirements)- .----------- ----------------------------------- ------------------------- --- • ----- -------- --•----- -- ................ <br /> t ri, <br /> ef7 et. l Vis..-... ri1�F. - ..�.. == � ... --....- _ --- ------------ ..---------- ¢-----------... - <br /> ,'- _----------- - -------------- ------------ - -------------- <br /> ----------��. . <br /> A1 (Draw existing and required addition on reverse side) <br /> I I hereby certify that I have prepared this iapplication and that the work willb done in accordance with San Joaquin County <br /> Ordinances, State Laws, and<Rules. and Regulation ss of the'SimdJoaquirii Local-Heaith�Distri.ct. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of.-.the work for wliich:�tliis•-permit-is,issued,ki=shall nal-employ any person in such manner as <br /> to become subject to Workman s'-Compen af <br /> w3`o 'Califo'rnia:"-~ -- ~• •-~"�"- # <br /> I $Y Title... ` T ' _ <br /> .................. <br /> (If other th wner) �^ <br /> OR SPAR ENT_.YIE ONLY <br /> APPLICATION ACCEPTED BY.......... --� ---------- i ` -- ------ - ------------- -DATE..- -------- ------ --- --- ------------------- <br /> DIVISION OF LAND NUMBER'....----. --------------- -DATE. <br /> ADDITIONAL COMMENTS--------- ------------- --- ------------'.. <br /> ----------------- ---- <br /> ................. . . <br /> ----- <br /> Fina! InsAecnon by - --- ......... Date <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FaS 21677 REV. 7176 3M <br />