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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> Permit No..------------------- <br /> (Complete in Triplicate) <br /> ----------------­--- ---------------------------- <br /> 7d <br /> Dote Issued---------------- <br /> This Permit Expires I Year From Date Issued <br /> ------------- ---------------- <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 /> JOBADDRESS/LOCATI N.)"e.�. <br /> ------------------------CENSUS TRACT-------------------------------- <br /> I , <br /> ', Owner's <br /> RACT----------- --------------------Owner's Name- <br /> Phone-gr <br /> L <br /> Address_ ,4el)�Y4el- <br /> -- ---------------------------- -------- ---------------city- ------------Z i PJKY ---------- <br /> ------------ <br /> Contractor's Name--.,a, <br /> --------------License n2 <br /> In Stall diion'will serve.v kesiden�ceg;-.-'�' Apartment House <br /> Commercial ❑ Trailer Court ❑ <br /> Motel El Other--=- - -- - <br /> Number <br /> ther----- <br /> Number of living urtits;-----------------Number.of bedro;ms'ff------Garbage Grindor.........:FCot Size---------------,777�,------- ------------------ ........... <br /> Water Supply. <br /> .Pyblic System and name--- ------------------ --- -------------- ....... <br /> ........... ...............----------------- -I------- ----------------Private <br /> Cloy L S <br /> Character of soil to a depth of 3 feet: S�ncl C] �Sjlt-L' Cloy ❑ Peat E) ,5ndy Loom Ej <br /> . . 0. o- , 6am El <br /> Hardpan E] A I aobe teric1j.__._.-------If yes,type-------------------::7! <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,etc.1must be-plo'ced on reverse side.) <br /> A %K <br /> NEW INSTALLATION: '{No`septic tankIor seepage Oicperm— itted if public sever is available within 200 feet' <br /> PACKAGE,TREATMENT SEPTIC TANK size-- --------- ........ ----------•------ Depth.._.... <br /> • ---- <br /> Capaci -------I-----Liquid <br /> Compartments---. ----------..-.---:.. <br /> ------------------ ...... <br /> pe- Material------------.... ........ o.' <br /> Distance to nearest: Well_,W,_ ........ ---------- Found ation- -----------...Prop. Line, <br /> -- ------------- <br /> LEACHING LINE ------- each I!no,.. <br /> jj No, of Lines..__...............................Length of <br /> e; <br /> V Box' <br /> Filter MateriaT.�_-;;I.�- Depth Filter MateiriaL.-An6_1-------- <br /> Distance to riecrest. Well----------- - _-Foundation------ ------------_ ----Property Line---!--*-------------------------- <br /> SEEPAGE PIT Depth........ ---------f.,A-1.1sivm�er Rock Filled Yes[3 No <br /> Water Table D;j�th-------------------------------------- <br /> ---------------------Rock.Size_!n_t_. ....... <br /> - --------------------------------- <br /> Pistanit6 to nearest. Well_ .............. _'t---------Foundation---------------------------Prop. Line-------------------------- <br /> a 1. <br /> REPAIR/ADDIT16M {Prev. Sanitation Permit#____.:___._ ------------------------- ........Date---------------------------:--------------- <br /> Septic Tank {Specify'Requirements)----- -------1. ------ -------------••:--------------=---------------------- ---------------­------- ---------------- ------ <br /> Disposal Field [Specify Requj'rements)-------t <br /> -------------------- --------------------------------------------------------...-----•- <br /> - -------------------------------- <br /> ----------------------------------------I--------- <br /> ----------i................... ------------ .........----------------­-- --------------------- ---­-------------- .......-11:------------------- <br /> ----------------------------------------------- <br /> ----­-----------------­------------ ----------------- -------...--------------------•-- —---------------------- --------- -------------------------------- <br /> (Draw eiki'.51ng arid-required-ddditid-n-d-h reverse s'i8e)_—' <br /> I hereby certify that.] have prepared this application and that-the-workNvill bi'done in accordance with Son Joaquin County <br /> .Ordinances, State Lows; and Rules andr Regulations of the Son JoaquinNiocal 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 li isiued, I shall not employ an person in such manner as <br /> to become subject to. Workman's Compensation laws of Cafifornia.".. <br /> Signed <br /> ­--------------- ---------- --I. ................... Owner <br /> By-------- --------- <br /> - -------------------------- --------------- ------------------- ------- ------------------- ---------- <br /> _.Title- <br /> --------- <br /> (If"ot-her than-6wrier)_ <br /> FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED,' BY____ - <br /> -------------------------- <br /> 2.r-------_------ <br /> DIVISION OF LAND NUMBER. ---------------- -------_------ --------- ---------.--DATE------------- --------------------------------- <br /> -- - -------------- ....-------- <br /> ADDITIONAL COMMENTS.__.....__. <br /> ------------------------------ ----------------­----------- ---•---------=--------------------------- ------- <br /> = -•-•------..---- •---- <br /> ------------L=-------------------------------------- <br /> -_------------­----I------------------------------------------- ------------- -----------------------------------------......... -------------------------------------------11- <br /> -- --------------------- <br /> ---------------------------------------------- --------------------------------------- <br /> - -------------------------------------------------------------- ------------------- ------------------------------------ <br /> ----------- ............ - --------- ----- --- .... .. ------- -- ------------------------------------ <br /> Final Inspection by:.. = <br /> -- ----------------j---------------------------Date ---------- <br /> 111 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Pas 21677 REV.7176 OM <br />