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FOR OFFICE USE: Ix`"' FOR OFFICE USE: -t <br /> f APPLICATION FOR SANITATION PERMIT � It.� <br /> -..,� <br /> ......� Permit No..7r 4_15,6 <br /> �; {Complete in Triplicate} <br /> . .. ....... .... Date Issued-. <br /> ...................................................... This Permit Expires 1 Year From Date issued <br /> oplication is hereby made to.the San Joaquin Local Health District for a permit to construct and.install the work herein described. <br /> k +is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> A. <br /> 3 --- ---- - <br /> --------- CENSUS TRAC ....................----.------ <br /> B ADDRESS/LOCATION../.../..O.w -- - - .-... --- ------------- <br /> wner's <br /> ddress..N--amoe... 3. .. .� . . _ <br /> --.Phone.. � <br /> `....! •��- ----. <br /> ------- <br /> zip-----�.0. ....... .. Phone.-.-- --- <br /> - <br /> ontractor's Name. � License <br /> #. <br /> stallation will serve: Residence ❑ Apartment House Commercial [D Trailer Court E]Motel El Other... .------------••---------- <br /> umber of living units------------ ---Number of bedrooms.....--. Garbage Grinder-...........Lot Size.--G.��.... .. -- -------------------- <br /> Pater <br /> ------- --Pater Supply: Public System and name......................... .... ... .. ----- --Private' <br /> )aracter of soil to a depth of 3 feet: Sand Silt [I Clay F1 Peat El Sandy loam E] Clay Loam E]Hardpan ❑ Ado e ❑ Fill Material.. .... ..- If yes, type----------------------- ---- <br /> got plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) ~ <br /> yW INSTALtATION: (No septic tank or seepage pit permitted.if�public sewer is avail le within 200 feet,j <br /> Li uid Depth....-T.- 0 <br /> -\CKAGE TREATMENT [ ] <br /> SEPTIC Size ..7 - -Z - 4--. �`.-- :---- - - q O <br /> Copacity.a--7.01 . YP ex, Material.'- 1` -------:No. Compartments...........a�'� k.... <br /> .. T e <br /> Distance to nearest: Well_-. -------.....�...-.--- e- --- <br /> ----.Foundation--/ - - ------ -- Prop. Line--.�--... --.. <br /> :ACHING LINE No. of Lines ----------------Length of each lines -- Q--. -d..-. Total Length.- - ---------...--... <br /> 'D' Box-.v. ..Type Filter Material.s4.1?,4 e-wlDepth Filter Material....... -- ---...... <br /> Distance to nearest: Well-/6.�.�- ._.....Foundation-_Ae........---.............Property Line... .... .._ - <br /> -F� /6)e/O..Number.-----.-�----- ......--. , Rock Filled Yes �"�lo <br /> T [� Depth...�U-..- - Diameter--. -- � <br /> Water Table Depth-----------3.6........... ..._-••-----..............Rock Size...c:17,1<-3............................ e <br /> 01 <br /> Distance to nearest: WeII-QQ....--.... .- <br /> Foundation.... - .. ......Prop. Line... <br /> =PAIR/ADDITION (Prev. Sanitation Permit#--------------------------------... ..... .........Date.................................. ------•---) <br /> R <br /> , <br /> optic Tank (Specify Requirements)...... .. . .... ........ ...--.--..... <br /> )isposal Field (Specify Requirements)--- -- --------------- ----------------........-.................................................. <br /> . ..--_............ <br /> ------------------------- --------------------- . . --------------...--------------- <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> )rdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <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 /> z beco Aeb ti (t to Wo an's ompensatiari laws of California." <br /> igned.. ..' .-.. �.� -..... Owner <br /> 3 ............. ......... --.- .�1.��� -�.. ........-Title ...... <br /> ----- -------- ......... ----------- ..... <br /> (if.other than owner) <br /> I F PAR MENT S NLY <br /> APPLICATION ACCEPTED BY................ ....... -•-- -.... . .... -------•-- -----•------ <br /> ....DATE ....... ... ..-- ..... <br /> 3IVISION OF LAND NUMBER........- . ...................DATE......... --....... . ........ <br /> ADDITIONAL COMMENTS......... ........................................ .........-.... <br /> --•.............................:......•-----..... -- --.------. -----............. <br /> ................ --------------- '....- -.-: <br /> - -;-----•--------------------------------------- ----- <br /> Final Inspecfion b Date -..-. <br /> EH 13 24 SAN tAQUIN LOCAL HEALTH DISTRICT s 21677 REV. 71P <br />