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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- ----------------------------=- 7 fl Q <br /> (Complete in Triplicate) Permit No__ ________ _l.__1 <br /> --------------------------------------------------- <br /> Date Issued_aZ.-__.__~ <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 /> ...._,..d <br /> ` <br /> ... . _,. T. -- <br /> JOB-ADDRESS/LOCATIO 4. `t-� -----------------=----------- ENSUS TRACT - <br /> PhoneOwners Name------- �� -- -' - _ <br /> ---- -:------------I--- <br /> Add ess- �" " ' A - ----- --- --------- --- <br /> r --- ----------------- city Zip <br /> Contractor's Name------- a--- a - -+.......License # _ . ---Phone ----- ----- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> >j t - ' <br /> � -Motel ❑- -Other_ -+- <br /> -`WatNumber of living units:-------r- -------Number of. bedrooms_.- ___-Garbpge Grinder., -Lot Size----. --- --- <br /> Water <br /> er Supply: Public System and'name--------------------------- -------- ---'----- --- ----- ------------ ------------- ---- -----------------—---------------Private <br /> Character of soil to a depth of 3 feet: Sand Q .Silt❑ Clay ❑ Peat ❑ Sandy Loam [❑ Clay Loam ❑ N <br /> .. Hardpan Adobe ❑ Fill Material__._. If yes, type :___ <br /> Z <br /> (Plot plan, showing size of lot, location ofhsystem in relafion to wells, buildings, etc. must be placed on reverse side.)~. <br /> ..s <br /> NEW INSTALLATION: '(No -septic tank+;or seepage pit permitted if'public sewer ss available within 200 feet `' <br /> r"i cif � <br /> TREA7MENT [ J SEPTIC TANK [ ` " Size___._S_____._X_�_0__-__---"' E""S. Liquid Depth_---- -------- <br /> PACKAGE ____________ i <br /> Capacity_._ 1_C�_0-:.= - - - °r -Mate•riaL•_. -__Na. Compartments--:----- ------------------- <br /> 'Type -- �, <br /> Distance.to nearest:.Well__ .. + a .-- Foundation-.'--- Q_ ____________Prop, Line---- ------------------- <br /> LEACHING <br /> ___.ilr <br /> LEACHING LINE' [1� No. of --------Length of each line ........Total Length _- --" _.__ <br /> D' Box ___..,..Type Filter Material'_ ___. ---fz,_..De th Filter Material----------)1- --- ----------------� _---__ ____-____ <br /> Distance:to nearest: Well__.. __ r ---•----.Property ----------__ -- ---- <br /> t oundation d?:_� Pr Line F <br /> SEEPAGE PET ( Depth-_ ._y Diameter. _______ i Rock Filled Yes No <br /> ���. " Number---------------------- .Ze� --/. # ._❑ <br /> Water Table Depth._.:_____._ '�__- Rock Si <br /> 4 Distance-to nearest: Well ----- -I_$0"Q-----------------------Founda'tiori._.____J_0..----_---:Prop. Line -------------,_-----------. + <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__-_.-"_-------- - `' ------------------- ' - ------ <br /> ---------------------Date "- _----- ) <br /> Septic Tank-(Specify:Requirements)=-=--=----------- - _ -' :_ ------------------ --------------------- ------------ ------ <br /> - - ------------ - -------- - <br /> Disposal Field.(Specify Requirements); - -------------------------------- ----------- -------------- <br /> ---------------- <br /> ---------- <br /> --------------------------- <br /> --- -• <br /> ------------- ----- - -- - ---. -- -------------------------------- ---- ------------------------ <br /> --------------------- <br /> - <br /> -------------------_ -- <br /> i <br /> - = <br /> -------- ---------- <br /> ------------------------------- -------- ----- ---=----- -- ---- - ---- <br /> (Draw existing and required addition r <br /> 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: r <br /> g <br /> "1 certify that in the performance of the work for which this permit is issued, I shall riot employ any person in such manner as <br /> to become :subject to Workman's Compensation haws.of .California.'.' <br /> Signed--------------------------------- -----------...----- ---=- -- - -------=-----� Owner <br /> ------------ - ----- - <br /> - Title--- �L° �,� <br /> BY = :: <br /> (If other than`owner) " <br /> 'FOR'DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - <br /> -- ------ -------------- ------ -- ----------- DATE <br /> --- - '- ---=----- DATE- ----- ----------------------- <br /> DIVISION OF LAND NUMBER------------------ - -- -.:----------- - ----------------- - .:.-- <br /> ADDITIONALCOMMENTS-------------------- --------------------------------------- -----•---------------- - ---- ---------------=------------- -------------------- <br /> ______..._ _____.. __ <br /> M <br /> - e-' - -------------------- <br /> _ <br /> -----------------------------------------.__�_-----}yQ_"._/•/_-C_/_/----------�---_"_--._____;_------.__.....- __.___. _"--------------------------------------------- --------.----------- - <br /> --------------- <br /> Final Inspection by:_-_ ---- --- <br /> -------- --------------"`------------------------Date__----- <br /> SN JOAQU 67-'- <br /> eN 13 24 IN LOCAL HEALTH DISTRICT Fes 217 REV. 7176 3M H <br /> �� <br />