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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> y (Complete in Triplicate) Permit No.._ d:.` 6 <br /> ... <br /> F. <br /> This Permit Expires 1 Year From Date Issued Date Issued..-. <br /> f Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> chis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations; <br /> JOB ADDRESS/LOCATION...... .--3 -7�" ....S.-- -, !-�' �' <br /> Yea. ._-.- -- �= °`'---------- --------------CENSUS TRACT - <br /> wner's Name.... . .. . ...kF .��, . ./- <br /> ....... ....................... .... ........Phone <br /> iddress -- <br /> Contractor's Name..... .--- ... '.C�.L._ --- <br /> ---------­......... ......... . ..License #_...--. ----_-...----- .Phone....- =-�------ - <br />�I <br /> F-1 stallation will serve: Residence ❑ Apartment House E] Com rcial Trailer Court ❑ <br /> Motel ❑ Other_. �e <br /> umber of living units: ..-..r>_ .._Number of bedrooms....._ ...Garbage Grinder------------Lot Size........_ <br /> Vater Supply. Public System and name---........... --------- ----------- ----------- � -- -------- -------------- Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay [) Peat ❑ . Sandy Loam 0 Clay Loam <br /> Hardpan [❑ Adobe ❑ Fill Material.....- _...If yes, type---------- ------ <br /> ---- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> EW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> - ` <br /> r;Z,'ACKAGE TRI=ATMENT [ ] SEPTIC TANK � �Oo --_".""..-_ - - ."..-_Liquid Depth---- <br /> Capacity. <br /> e th.--.��.�...�............ . <br /> Size.-... - ....----�- W <br /> Capacity. � .00--------TYPe �'C"c s ..Material-.GQ.�+t_r`e- r-.:No, Compartments....--:.Z.-... <br /> Distance to nearest: Well-._.../ Q f"- <br /> Foundation..---. .. ......... .-.Prop. Line ft6. .". <br /> LEACHING LINE <br /> [ ] No. of Lines - -------.....Length of each line----------- 0---......... Total Length .. .---.-. 4..e <br /> .......... . <br /> D' Box--.._ ...Type Filter Material <br /> / <br /> YP - r.rL{�? Depth Filter Material �. ...- ---...I.................... . <br /> F, Distance to nearest: Well------- fl---_--- Foundation--.---7-14----......Property Line.._.----->L -�.......... .... <br /> vvy. f � 7 <br /> T [ ) Depth...._./-�.....�-_�I X I4 ....Number- --------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth r— -----I-2.0-..... <br /> ----- --------- <br /> -----Rock Size--..-� r� �--- ------�------ - - <br /> Distance to nearest: Well............;�!. 4Q-------------------Foundation....._;;>_t-2. ...-- Prop. Line...-------------- ....--.. <br /> EPAIR/ADDITION (Prev. Sanitation Permit#--------------------------- <br /> -.-----..--.---- ) <br /> ----------- ..--- <br /> �eptic Tank {Specify Requirements)....-- .---------.- . <br /> Disposal Field (Specify Requirements).........._..------ : -. _ <br /> ---------------- ------------ ------------- .......... ----.......----- ---- . ----- --- .......... . .--.-----..'. <br /> ............ --------------- -- ------------- --------- -------------- - ---..... . -----:..-----.------..---- --------- <br /> (Draw 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 <br /> signature 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 /> ro become subject to War '* Co ensation laws of California." <br /> f <br /> r31 igned-.-----..- � Owner <br /> y----------------------------- ------------- - .....Title...- -- .....---- <br /> (If other than owner) <br /> FOR EPA TMENT USE ONLY <br /> APPLICATION ACCEPTED BY__......__ <br /> - --... -- -- --- �- -- ��-----... ....... --�------- - ------------DATE � �.y...7.�- --._.... <br /> DIVISION OF LAND NUMBER--------------- -------- " <br /> - ---- ---------- - -------- -------- -- ------ -- .-...DATE....._...---.....-.....-- <br /> ----- - - <br /> ADDITIONAL COMMENTS.. ' <br /> .......... ------------------------- ........ <br /> ------------------- <br />_'------------ ---------- -------------- <br /> .------------ ------- <br /> ------ �•' e,:�?' ......... ................ <br /> 'Final Inspection by:... � f <br /> ----------- -- - Date �' <br /> CH 13 2' SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> - I <br />