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"USE.1 ,.,,_., PERMIT '' APPLICATION FOR SANITATION PE r OFF <br /> �` pf 10E <br /> ii <br /> Permit <br /> ...................................... .....----- - <br /> No......---•---•---•....- <br /> "-- (Complete in Triplicate) <br /> = 11- ..a= <br /> Date lssued -------------- <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 ade in compliance with County Ordinance No: 549 and existing Rules and Regulations:. <br /> � c <br /> Owner's Name .... . - - - ...._. . . CENSUS. TRACT--------------------------- <br /> JOB ADDRESS/LOCATION:.....- !L. -... -----------.]-....._. .-G.u-� . . .�.li..--. <br /> (� "Q.il.` ..... -- - = Phone <br /> - - .--- <br /> �. :: ...:.........City---- - (Q <br /> Address- <br /> - i <br /> 4� ] Q r ` Phone-OL <br /> t0........". i <br /> Contractor's Name..-- <br /> License #- =ti <br /> Installation will serve: l� Residence Apartment'House ❑ Commercial [I Trailer Court ❑ <br /> i Motel ❑ 'Other........ --------------------------- <br /> Number of living units------- <br /> ------ --Number of bedrooms....?farbage Grinder. -.. ..Lot Size,......-- -"• .- - - - ---- <br /> l .....................Private ❑ <br /> 11 <br /> Water Supply: Public System and name..__�1U! - •. ' - �� <br /> 1 1' Sand Loam ❑ Clay Loam ❑ <br /> Character of soil to a depth of 3 feet; Sand Silt [] Clay ❑ Peat ❑ Y• <br /> Hardpan ❑ Adobe f] Fill Material- if yes, type----------------------------- <br /> (Plot <br /> --•------------- ---(Plot plan, showing size of Iot,'Iocation of system in relation to wells, buildings, etc. must be placed on reverse side.]. <br /> NEW INSTALLATION: (No 'septi tank. or seepage pit permitted;if 'public sewer is available within 200 feet,! <br /> ",` Liquid Depth... + <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size... -..."--- -------------------;--- - <br /> Capacity ----TYpe................ ......Material—----- ------ No. Compartments. -------------- ---- ----� <br /> --- -- . <br /> Distance to nearest: Well---=----- ------- .. ... ......... -..Foundation-•---- Prop. me C� <br /> Total Length -- -------------- -------- ------ <br /> LEACHING LINE [ } No. of Lines --------------------- Length of each line ----------------- g <br /> i C <br /> F Di taox :-.... -.Type Filter Material----... ----- .Depth Filter Material.. -- �---� -----�------ - ------------�-- --------• -� ----... <br /> D s nce to nearest: Well.---------------------------- <br /> Rock <br /> -•---------------- ------ Foundation..----....--------- Property Line...-------------...... <br /> -------------- <br /> Distance <br /> ------------- <br /> SEEPAGE PIT [ ] Depths... .......:..Diameter----------- Number.,.. <br /> Rock Filled Yes ❑ No❑ ' <br /> ---- <br /> Water <br /> Rock Size-- --------- ---- ------------------- <br /> rTable Depth.---•---------•-------------- --------------- <br /> I . Prop. Line------- ------- - --•-- <br /> Distance to nearest: Well------------- - Foundation -- <br /> il --------- <br /> i <br /> REPAIR/ADDITION (Prev. Sanitation Pert-hit#......-----•--------- ----- ------- --- -- ----- ate------�-_--.,.-------- -- -�­k- <br /> eX7 Oft <br /> Septic Tank (Specify Requirements). ---/2-0-a-.: � - ....... .... .......... <br /> Disposal Field (Specify Requir"ements) --- ---'- ----- - --------------_------------ <br /> ------- -- -- ---•---- <br /> -------- ••----•----- <br /> ....--....- ...--- <br /> - <br /> (Draw existing and required addition on reverse side] <br /> I< <br /> I hereby certify that I have prepared this application and that the work will be done h. County <br /> accordance with San Joaquin <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Loca!'Health. District. Home owner or licensed agents <br /> r signature certifies the following: <br /> l "I certify that in the performance of the work for which this permit isued, I shall not employ any in such manner a <br /> �issperson" <br /> to become subjects tWoorrkman's Compensation lows of Caliiorniq <br /> Signed... � - tY� Owner <br /> : " <br /> �;;.�• `--== ;.--- <br /> B ...-- ........------------- ---------- ............... ....... Title----- -------- <br /> (If other than owner) <br /> ;. FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.- .... .. <br /> ` .-DATE _ .�---- -- <br /> ..... ----- <br /> F -----... . DATE <br /> DIVISION OF LAND NUMBER--------- -------' .: <br /> ADDITIONAL COMMENTS..��-.. ... <br /> i . <br /> -- -- -- . . . ........... - ------ ------ <br /> 1-1 -- <br /> l .-....t-------------- --- - , - - <br /> ----- ... <br /> -------------- • •......- -------,- � � Date.. ----1-r - <br /> ...... ...m--------------- ------- <br /> Final . <br /> .... <br /> Inspection b ' <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />