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FOR OFFICE USE: I 0 FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit <br /> Date Issued fes_-17-_�� <br /> --------------------------------------------------------- This Permit Expires I Year From Date Issued <br /> .w. tea. .—M <br /> Application is hereby made to the San JoaquinLLocal.HealthYDistrict for a�permit,to construct and install the work herein described. <br /> This application is ma e i ompliance witW,-County,Ordinan`ce No'.-54.9 ar'8"existin `,Rules and Regulations: <br /> JOB ADDRESS/LOCATION__--- -_- -- - <br /> I <br /> -` -- -- - - -- -------- -- --------- ---------"y__l_CENSUS TRACT------------- ---------- <br /> Owner's Name. - --------------------------------------- ---------- --- ----- Phone <br /> Address-----1--------_- � � - -- -----------------------------City----- --- ---- ---- ----- -----------------Zip------ <br /> i <br /> Contractor's Name----- --- - License # Phone_ . <br /> Installationiwill serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> �i _Motel_❑. M:,C3ther�w� <br /> Number of living units:.____[______Number of bedrooms__.__")----Garbage Grinder Lat Size___ v'.7 .l ._ <br /> Water Supply: <br /> u PP Y=of soil toic Ystem e depth of d name . ----------------------------------------------------- -------------------------------------- ----------------------------------Private <br /> + <br /> Sand ❑ Silt❑ 'Clay ❑ Peat Ej Sandy Loam Clay Loam ❑ <br /> Hardpans❑ Adobe ❑ Fill Material-- --------_If yes::tYPe"�- ------------ ---- -- I <br /> } <br /> 'Plot plan, showing­s�e of�lot, toeation of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION- � (No septic fank`or seepage pit permitted if public sewer is available within 200 feet,] y <br /> PACKAGE TREATMENT {[�' SEPTIC TANK <br /> t ---------------d4I Liquid Depth_ <br /> ! <br /> 4 � A l� <br /> - I <br /> Capacity <br /> ,)-- 010----Type--�-------------Material r'y'L--- ---------No. Compartments------�------------------ --- <br /> ` 1 - '----- -- Length of each line-le tion-_,i�p- ----=-°[------Prop. Line--�-~--------------- <br /> LEACHING; I ' <br /> __ <br /> _LINE'. [ a . No. of Lines----�_.--_-�. - -• g ---------------------- -Total Le�lgth..�_1�----------- <br /> lstance;to nearest: e.____.____.__ _-Foundation <br /> D''Box T : e Filter Material''______ __________De th Filter Materia[--_/._�______. <br /> YP p <br /> Distance to nearest: Well----------------------------Foundation----------:-----------------.Property Line----------------------------------. <br /> PAGE PIT De t <br /> [ ] Ph__.._.-- -------Diameter----------------- --Number---�------�----.------_--- <br /> - - -_ Rock Filled Yes E] No E]SEE <br /> Water Table Depth----------------- --------------------------------- --- Rock Size------------------------------------------------ <br /> Diknce to nearest: Well--------------------- ------=--------- ----Foundation-----L-------------------.Prop. Line-------------------------- <br /> AIR/ )ITION <br /> ------- ------ -------AIR/ADDITION ,{Preva Sanitation Permit#---------------------------------------------------Date.-------------------_----------_------------) <br /> , t f : <br /> SepticTank(Specify Requirements) -' = = ----------=--.-------v--------- --------------- - ------ ------------=--- ------------------------------------------------------------ <br /> DisposalField (Specify Requirements)----- ---------------- ------------------------'-------------------------------------- -.-------------------------------------- = --------- <br /> --------------------------------- <br /> - ..------------------------------- ------ -------=----=-----------:------------ --------------------------- ----------- ------------ - --------------------------------------------------------------------- <br /> : ;: ----------------=-------------------------- ----------=----------------------- ---------------- ------------------------------------ ------------------------------- <br /> {( (Draw existing and required addition on reverse side) 9 <br /> I hereby.certify that I have prepare s# 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. Horne owner or licensed agents <br /> signature certifies the following: <br /> s: <br /> "I certify that'in the performance of the work for which this permit is issued, ,I shall'nof employ any person in such manner as <br /> to becomes subiectY fo Workman's Compensation laws of California." j <br /> Signed = = Owner <br /> BY- <br /> --- --- ---- ---' ---- --- - Title --- ---------------------------- --------------------- ------ <br /> (If�other than owner) + <br /> t <br /> FO DEPARTMENT USE ONLY` <br /> APPLICATION ACCEPTED BY-------- 9 ---DATE...--_/-2--7----�------ --.--- <br /> --.---------------------------------------------------------------- <br /> DIVISION OF LAND NUMBER.......... -----'---------------------------------------------- ------------------------------- --- ---DATE------------------- ------ --- <br /> ADDITIONAL COMMENTS-----------------=-------------=------------------------------------------------------------------- --------------------------------- <br /> t . <br /> ------------ ----------------- ---------- -- --------- ------------------------- ------------------ - --------- - ---------- ---- --------------------- ---- <br /> i <br /> -----------------.---=------------------------- -- -- --- --- _ - - - - - -- <br /> Final Ins ection b f ------------------------------------------------ g ' <br /> e <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> L- <br />