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FOR OFFICE USE: FOR OFFICE USE: <br /> _.APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- (Complete in Triplicate) Permit No----------------------- <br /> --------••-------------------•--------------•------ <br /> Date lssued____���_.�� <br /> . <br /> ----------------------------- ------- <br /> ------------- This Permit Expires 1 Year From Date Issued <br /> 17plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> T is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----� ��` (� ----- .�' CENSUS TRACT -------- -- -- ----- <br /> `br:` <br /> {�Nner's Name - t--`' = - -------------- - Phone <br /> t P r1i ! <br /> Address P `'� City- -- ---- ---- --------! -------Zip-- ----------- <br /> —)ntractor's Name--- ` -----------: -:--License #- 3 �_ Phone------------------ -- ---------- <br /> �...stallation will serve: Residence Apartment House.[:] Commercial ❑ Trailer Court ❑ <br /> Motel F1 Other--------------- ----------- <br /> 7 <br /> --- ----- <br /> � <br /> - J­ <br /> LimbfLimber <br /> livingunit -------Number of bedrooms----3---Garbage Grinde-r------------Lot Size-_ ,_7_.S-------------------------------------- <br /> Cater <br /> __ ___________ <br /> , r5upPY: s stem and name- - ----------------------- --------------------•--=-------------------------- -- ------ <br /> _ <br /> I--------------------------------------Private <br /> aracter of soil to a depth of 3 feet: Sand [:] Silt E] Clay EJPeat E] Sandy Loam ❑ Clay Loam El{ Hardpan Adobe C] Fill Material--------._"af Yes, type-------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, btfildings, etc. must be placed on reverse side.) [ <br /> EW INSTALLATION: )No septic tank or seep ge pit permitted if public sewer is available within 200 feet,) <br /> rACKAGE TREATMENT [ ] SEPTIC TANK [ Size_ _,[ =__ __-: -__ -----------------Liquid Depth ------------------------ ` <br /> .I <br /> No. Com artments________ __ --------------------- <br /> ----------- <br /> __ <br /> - CapacifiY--[�-O--�-------TYPe ---- -------- -----Material ----- -------- p ------------------ �F <br /> s Distance to nearest: WeEL__________.� _ -___.______Foundation._._,_ _( __ _.Prop. Line._: _. - _-_- <br /> i <br /> LEACHING LINE [ <br /> 140-0- <br /> -,,/Distance <br /> of Lines-------,3_-,---------------Length of each line------ �l_ratedal <br /> _______Total Len ---?_�4__ _ ------------------ <br /> ---------------- <br /> F <br /> __---_----___-,-_ � <br /> D' Box-----I-----Type Filter Material---------S_R_-Depth Filter --------�_�-----------------------•---------------------:--- a <br /> Distance to nea est: Well------ _�_L`1`---Foundation._____._--b.- -----Property Line_____ _____ ____ ---______ ' <br /> �EPAGE PIT [ Depth.__ZDiameter____ _ ________Number------ _______________ h r, Rock Filled .Yes. o ❑ <br /> Water Table Depth------ ------------ ---------- Rock Size } ---3---- <br /> I' /-- - Prop. line------' <br /> .Distance to nearest: Well-------- ______ Foundation.__ li----�"�--. <br /> EPAIR/ADDITION {Prev. Sanitation Permit#---------------------------------------------------Date----------------------------------------------1 <br /> _eptic Tank (Specify Requirements)_________________________ <br /> -- ---------------------------------•-•------------------------------------------------ ----------------------------------------- <br /> Disposal Field(Specify Requirements)------ --------------- ------------- ------------------------------...---------------------------------------- <br /> ------------------- ------------- --------------------•----•------------------------------------ --------------------------- <br /> --------------------------------------------- ----------------=----------------------------------------------------------------------------- -------------------------------------------------- ------------- <br /> (Drew existing and required addition on reverse side) <br /> 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 j <br /> ignature certifies the following: <br /> `I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Wo man' Compensation laws of California." <br /> igned---------------- ------------- ------ ------------------------- --- ----Owner i <br /> aY--------------------=---------- `> + -- �- ------------------------------- }' <br /> jl of er than owner) <br /> F9LR DEP R;LSE ONLY <br /> APPLICATION ACCEPTED BY DATE;_ . ` I <br /> DIVISIONOF LAND NUMBER-------------------------------------------- -------------------------------------------------- DATE---------- ------------- -------- ------ <br /> ADDITIONALCOMMENTS-------------------------------------------------------------------------- ---------------------------------------------- ----------------------- ------------------ <br /> ------------------•--------------------------------------------------------------------------------------------------- -- ------------------------------------------------------ ------ <br /> ----------------- - <br /> �: ------- ---- ------- <br /> - / i <br /> Final Inspection by------------ ------- --- {moi— Date. - <br /> ,EH 13 24 SAN JOAQUIN LO AL HEALTH DISTRICT F&5 21h77 REV. 7/76 3h <br />