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FOR OFFICE USE: FOR OFFICE USE: <br />{ APPLICATION FOR SANITATION PERMIT <br /> 2 a p m- 3� <br /> ------------------------------------------ - ------- <br /> {Complete in Triplicate) Permit No.-__7 ------------ <br /> --------------I--- -------- ----- <br /> Date Issued--- ---------- <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/LOC ON S-. - KJ ----- --------*__,_,z°`�-�-'------ ------.CENSUS TRACT--------- - ---- ----------- <br /> i ' <br /> Owner's Name.---- : --=------------ ----------------------------------------------------- ------------ ----- Phone-------------------------------------- <br /> _rw <br /> ------------- , � ..................Cit ------------ Zip <br /> ------------------------------ <br /> Address-- <br /> - ------- - -- ----- 1:19 X7—Name ---------------- - - - -----Phone <br /> Installation will-serve: Residence [Apartment House.❑ Commercial 0 Trailer Court ❑ <br /> Motel ❑ Other----- ------------------------- ---------- <br /> Number of living units:_. 1__-------Number of.bedrooms--.--3-----Garbage Grinder------ r_ Lot Size---------.e0-0_ _ ------------------- <br /> i Water Supply: Public System and name---------------------�~ ` ' _____________Private <br /> Character Zr <br /> of soil to a depth of 3.feet: Sand ❑ Silt❑ Clay❑ peat❑Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ . Fill Material-------------If yes, type________________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) _T <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 4' <br /> a 'A <br /> [ ] r- -- ----- - - - -------- ---Liquid Depth----------------------- <br /> PACKAGE TREATMENT [ ] . SEPTIC TANK : Size_-________-_ _ --- <br /> � 5Ca <br /> Capacity - = Type ------- ` -_--- Matarial ± -----------No. Compartments_______________________._-__'_._ <br /> r ' <br /> -5 <br /> Distance to nearest: Well—____.? <br /> # Well - -• foundation-- ---------- <br /> ••••y--Prop. Line_,_.______________________ <br /> __ <br /> LEACHING LINE No. of Lines -.---. L ngthofeach line----------------------- --Total Length---------------------------------------- <br /> `D' <br /> ________ _______________________ __`D' <br /> Box---- --- ----Type Filter Material t_________________:Depth Filter Material_-____-_________-_.____ <br /> ---------------------------------------- <br /> Distance to nearest: Well--------`------ ----------Foundation---------:-----------------Property Line------------------------------------ <br /> 16 <br /> SEEPAGE PIT [ ] Depth----------------D,iameter_'__.----------------Number--------------------------------- Rock Filled -Yes ❑ No ❑ <br /> Water Table Depth----- - --=-- ---- -- _ <br /> - --'--------------------------------Rock Size------------ ------------------------------------ <br /> Distance <br /> - - -- -- -- ------------Distance to nearest: Well-------------------------------------=-------Foundation:------------------------ Prop. Line----------------------------- <br /> REPAIR/ADDITION <br /> -.--------------------:-_REPAIR/ADDITION (Prev. Sanitation Permit# - ------------------ = Date ). <br /> m.. mom_. _ - �---- . <br /> Septic Tank {Specify Requirements)___ ""___-_._---"""_ !'____________ ' " - <br /> E f <br /> Dis sal Field (Specify-Requirements)_G .- !� ___.-_ �"`+°_`_ _______ <br /> -------------------------- <br /> --• Q------ -- = -- 3- ----- ., <br /> 1 X ! - = -----------------------=-----------------------------------------' <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 /> all 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 /> 60 <br /> By- --= _4_.___,_Title <br /> € <br /> - <br /> r (If other than owner).. <br /> t FOR DEPARTMENT-USE ONLY t <br /> APPLICATION ACCEPTED BY----- ----------- ----------- ---------`!---- -----=------------------._ DATE -------- <br /> _ . <br /> DIVISION OF LAND NUMBER________ _____________ <br /> = -------.DAT --- --- ---- ----------------------------------- <br /> ADDITIONALCOMMENTS------- ---=-- ------- --=------------ - ------ --------------------------- ----:--------------------------------- ---------------------- <br /> ------ -- -------------------------------=---- --- ----------------------------- ----- ------ - ;� -------------------------------. <br /> i ----------------- <br /> --- <br /> f _______ _----- _ " __-_. _______________ <br /> 4 f <br /> f ________________________________Y.____'-_______ _ -_- /_Z <br /> ______________________ ________-____________ __ - ____ _____._______-_-_.- <br /> Finc11 Ins action b --- --- --- ------------- <br /> A - ------ <br /> p Y•---- ------ == ----- --- ------------- --- -Date <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />