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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> '�-- <br /> Permit No.��=- <br /> ----•-••------------------- -- <br /> - - -------•---- <br /> ��--�- <br /> (Complete in Triplicate) <br /> ---- ---------------- Date Issued._`r��: -2. <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 /> SI 2S-1 ----------------CENSUS TRACT------ --- <br /> ....JOB AQDRESS/LOCATION---. .. ---. - <br /> r <br /> G L =._.:... ... 3 <br /> �� -- - ----------------- ----------------Phone-..._... ........ <br /> Owner's Name_ �o•�J t ? A'f1�9. .. �� -.. -9.5"3.2 3---------- <br /> Gr L`ScA�c7-✓ Z;p-- <br /> Address 3.1.�.Sr.. .. _ . , oSS�c�YL...-R.. ---..-- . .. :... y---- ----------- - <br /> . �--License #----•- ------ ------------ Phone._.`~�--- ----" <br /> Contractor's Name- ........ ............ ....................... . .. . <br /> k <br /> Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court [I <br /> Motel ❑ Other-----_------------- ------------------------ f i <br /> • � <br /> Number of living units:-----------..-Number of bedrooms-..:.._... Garbage Grinder------------Lot Size------ <br /> - E <br /> Water Supply: Public System and name------------------ -------------------------------------- --- ------------Private E] <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loci <br /> -If yes, type- ._.. <br /> Hardpan ❑• Adobe ❑ Fill Material... ...- . . ' <br />,.mss. ---•-�..";�:- Y . _�. - <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 200 feet,] <br /> Size _....------- -Liquid Depth............. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] - <br /> ? Capacity.... ------ --TYPe........ ............ Material No. Compartments <br /> _ Distance to nearest: Well------------------------ -------- - <br /> .-Foundation-----__. . --.... .. ..Prop. Line <br /> LEACHING LINE l ] No. of Lines ... -------------Length of each line-------------------------------Total Length <br /> l , Box......----- Type Filter Material...... ......._..Depth Filter Material-- --------- ---- ...---- .. -------- <br /> Z �c ....Pra ert Line--------------------- ---. .. <br /> isfance to nearest: Well----- ------------------Foundation _.....Property <br /> 5 Rack Filled Yes ❑ No <br /> SEEPAGE PIT [ ] eptl.. ........... .Diameter..... - Number. <br /> Water Table Depth------------------------ ------- <br /> Rock Size - --- <br /> Distance to nearest: Well_----------------------- <br /> Foundation.-f......--.... <br /> ... ..._.Prop. Line-- .. .-- ....... <br /> I REP 3 �- .. ----- Date < L - --------------) <br /> AIR/ DDITIO (Prev. Sanitation Permit#------ ---- ----= <br /> Septic Tank (Specify Requirements)........... - ------.-.F'--- ¢" -- -- --- <br /> - -'// <br /> Disposal Field (Specify Requirements)....f-_---------•- ..-....." X, - <br /> ...... ........ .. .... > <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 /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner as <br /> I to becomeu lett to ork can's Compensation laws of California." <br /> I a Owner <br /> /�,� ---- ---------------- <br /> Signed--•'-- " 5� <br /> ' Title ............. ..... ------ <br /> • ..................... <br /> . llf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> k <br /> APPLICATION ACCEPTED BY... ...._.. � <br /> ------------------- <br /> --------------------- -DATE <br /> DIVISION OF LAND NUMBER...... ........... ...._.._..----- .--- . .------..................... DATE..--.....--............. <br /> ... .....-..,_.--------._------ <br /> ADDITIONAL COMMENTS....... ........ ...... ----------------------- <br /> ---------------- -------- --.._...ate ...._Q-. . - - <br /> Final Inspid6on by:.. ----- - ". F&S 21677 REV. 7176 3M <br /> L EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />