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FOR OFFICE USE: FOR OFFICE USE: • <br /> f APPLICATION FOR SANITATION PERMIT <br /> ------------•------------ I- 71 lJ <br /> (Comp#ete in Triplicate) Permit No.__........`........... <br /> Date Issued-_.J-4'--.?�� <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 w' h-Cou Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO _ N <br /> � .S f ��r14 <br /> 3 -Owner's Name..... Vi ..Phone.. . . .....--i---------- ------- --- -------- . ...... ---------- ••--- . '. <br /> ov. r�. `�+. _ _ .._.... Zip--ya a3-�-----. <br /> Address y......-.. p = <br /> Contractor's Name___ ---��. .� �..........._............ . License #----------- <br /> t1 . .... . ..... .------.-. Cit <br /> , <br /> - - -- .-•------ Phone - - <br /> Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court ❑ <br /> Mote! ❑ ther..�C t w�l-�° .-------- . <br /> Number of living units;..._......_....Number of bedrooms-..�:.._.....Garbage Grinder. --lf--_Lot Size...... .......... ....................:...:.............. .. <br /> Water Supply: Public System and name:........--- -------- ----....Private <br /> Character of soil to a depth of feet:._. Sand.E] Silt E] -Clay E]".- ' Peat El Sandy Loam Clay Loam ❑ <br /> i Hardpan ❑ ' Adobe E Fill Material.. - _ If yes, type..E....................... { <br /> (Plot plan, showing size of lot,location`of systemin 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,) c! <br /> PACKAGE TREATMENT [,]T SEPTIC TANK. . �4 Size............................... ...... ------Liquid Depth..............------------- <br /> Capacity-1,�• Q--------Type......---- -; Material..fe ........No. Compartments.............-- ------------...._ <br /> Distance to nearest: Well ..'_.r l..............Foundation.......... . ..........Prop. Lin�ee/---1- .�...� .. <br /> LEACHING LINE [ ] No. of Lines.......3-----------------Length of each line--------SO......... ...... Total Length .. ._�-l--Q....-- ..----...----� <br /> 'D' Box- '......Type Filter Material_ .----.Depth Filter Material------�-- ----------------------------------------------- <br /> Distance to nearest: Well---. .0.0..... XF aundatian---- ------------------Property Line.... � -T <br /> SEEPAGE PIT Depth.......-- -- Diameter- ---_ j_ -------Number -.-_. Rock Filled Yes No M <br /> Water Table Depth....... -- _-- -------- ---------• ....Rock Size..... � <br /> V <br /> Distance to nearest: Well------------------------ -----------Foundation.................. -.Prop, Line..--.----------------- I <br /> REPAIR/ADDITION {Prev. Sanitation Permit#------------------................ ..........Date,-------:----------------- ------------------] <br /> Septic Tank (Specify Requirements)-----.--------_---_---- •-------------------------------------;------------ ;•---------- -- ............ -- - ---------------- ------ •---- O <br /> Disposal Field (Specify Requirements)_—........-------... .......... <br /> ----- -- ----- --------- ------ - <br /> (Draw existing and required addition on reverse side} F <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 Mules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: ` <br /> "I certify that i the erformance f the ork for which this permit is issued, I shalt not employ any person in such manner as <br /> to become b' ct t r s Com nsation laws of California." <br /> Signed- ...,,. -- ----- r--------------•.. ---.Owner <br /> Titled 4 <br /> BY : .. ........... : '... <br /> If other than owner) Y <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY... / <br /> i .........DATE ... .�-----...---- <br /> DIVISION OF LAND NUMBER. . _. . :.... -.i DATE.;.............;.._-_ ------- !... <br /> -------------- --- <br /> ADDITIONAL COMMENTS...........------ ........ _ --------------------------- ............ ---- <br /> ... .._ .-... ......... .......... ... .. <br /> ... .i. .. ... ... ... .. - ---------.-....----.----- • - ..-- --. ------' - ..... ..-- -- <br /> . .. ._. E^l1� <br /> ­ <br /> ---------- ..... _ _ rr. ...u. .A �...�6.. w 1 .s.v:.........w...�..a <br /> Final-Insgecnon b -------------- . .... ..... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ray 21677 REV. 7/76 3M <br />