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FOR OFFICE USI:: FOR OFFICE USE: In <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No......7--. --------- <br /> Date Issued____________ ______ k <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 ules and Regulations: :"* <br /> JOB ADDRESS/LOCATION -;-.- -� --- --- - - ------ - I� -- -----------CENSUS TRACT ---------- ------ - <br /> Owner's Name = --Phone ---- -------- ----- --------- ------ <br /> Address_ <br /> --- E x---- 4t4-- ---- city <br /> Contractor's Name____. <br /> y .�- g-: � Phone---- <br /> Contractor's --------------- --- 1c <br /> L" ense <br /> M <br /> . _. ' + House E � Trailer Court s <br /> t � nce� Apartment House ❑ .Commercial ❑ ❑ <br /> Installation w111 serve: � Reside + Motel-0 Other---=-------------------- � • - -� - � � <br /> Number.of living units----------=------Number.ofl�edrooms -- Garbqge Grinder Lot�Size------:---------•_-------,•-.---'_------ ,------------ --- Q <br /> Waiter Supply: Public System and}name- �'� ------------- -- ----- --------------------------- -------- -------Priv to <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay ❑ : Peat E] Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material__ _______-If yes, type----------- ____________________ I , <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc.'.must be placed on reverse side.) <br /> NEW INSTALLATION: `-'(No septic'tank 'or seepage pit' permitted,if puhl.ic.sewer is'available within 200 feet,) <br /> PACKAGE TREATMENT [..] .. SEPTIC TANK..-[;`.�-..�a.. .. F Size `__ 1 `st-..�.-.,.. 'i. ' Liquid'Depth ------------------ -- ---- <br /> Material_:- t ; <br /> Ca acit <br /> Type---. <br /> = :No. Compartments +@ <br /> Distance`to nearest: Well Foun anon'j ---- -------- -Prop. Line . <br /> -- --- ---------- <br /> 9 <br /> LEACHING LINE No, of Lines-_.--! Length of•each line _,--.-- :�'�� Total Leng <br /> 'D' Box:_' <br /> _--Type Filter Material_______ ________ De th Filter Material_---- .�f�Q-� <br /> YP P .. # <br /> -- -- <br /> .Distance:to nearest: Well__------.---=4------.'_----Foundation�----I - -___-'___.Property Line-.---_______________________ ____ <br /> � <br /> SEEPAGE PIT [ j pepth_..' _--- .-.Qiameter- Number___:=.____ -_- ,.-- -- Rock Filled Yes ❑ No ❑ <br /> �. . . <br /> - ----,-- - - / <br /> Foundation <br /> Water Table Depth --- - Rock Size _ -- <br /> p <br /> Distance to nearest:Well -_. --Q'�-----:_..Prop. Line__��__--.-__ -. <br /> REPAIR/ADDITION (Prev..Sanitation Permit#__ _____-- �'_ _ - --• +_=:___a______.:Date_€__:'_----_-°______"_ - ----_] <br /> Septic Tank (Specify Requirements)-'---- =: # } 1 = <br /> Disposal Field [specify Requirements) # ' t --------------------------------------------------------- <br /> ------ -------`---------------------------------------------------------- <br /> (Draw existing and required a d oon verse side) ' <br /> 1 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:„ f <br /> I ' <br /> "1 certify at he peifo fiance of'the work'forVn!chis ermit is issued, I shall not employ any person in such manner as <br /> to bet* u ° to r man's Comp sgtion; lifornio.':,� <br /> Signed e <br /> ,Owner <br /> BY-5 = <br /> ------ -.-- ) - Title --. . I <br /> if other than owner <br /> - FOR DEPARTM NT USE ONLY: " 1 <br /> APPLICATION ACCEPTED BY- --- ---- -�= - ------DATE.`-----✓�� � _ -------- <br /> DIVISION <br /> --i--- y <br /> DIVISION OF LAND NUMBER------------------------------------------- _ DATE.---___.___-- - <br /> t � <br /> ADDITIONA COMMENTS. ---- µ <br /> •�. s <br /> .�------ <br /> -------------------------------------------------- --------- -- -_ --------.------------------------- <br /> 1 <br /> --------------------------------------- -------------- --- ------------------------- ------- ---------- ----- -----------•------------------ ---------------------------------- <br /> ------------- <br /> - <br /> --•--------------------------------------- ------`--..- ------- ----•' -'-=----•- - - ---, ----- <br /> Fina{ Inspection by_ <br /> ----------------=------- = Qate - '��i ="T t <br /> EN 13 24F&S 21677 REV. 7176 3M <br /> _ � SAN JOAQUIN LOCAL HEALTH DISTRICT <br />