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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 1 <br /> .......................... <br /> • . . ...........�•• (Complete in Trip(ieai®} q t <br /> Permit No. .� <br /> 7 <br /> ............. . ................. This Permit Expires 1 Year From Date issued Date Issued_-3.:/. <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 Rules and Regulations: <br /> JOB ADDRESS/LOCATION <br /> �---T. ................ <br /> CENSUS TRACT.._....._ <br /> op <br /> Owner's Name.-------- G,, .1 � l.-�'-�Er, - -r-.-�� _..`.._._...__. Phone4:.� :o C ?_ <br /> Address..., ._.._, V-';._ d�Y.'. l' �".` City f ��--_--------------- <br /> Contractor's <br /> - ._.Zip----- •- <br /> . - <br /> Contractor's Name-------- ------------•-••----•---- .......... =-•---- ----------- License'#........... ................Phone__........................ <br /> Installation will serve: Residence❑f Apartment House 4o mercial 'Trailer Court ❑ <br /> ♦ M etel ❑, Other_._` il .E,��gat� � - t = <br /> Number of living units----------.----._Number.of.bedrooms___ :.a_ jGorboge Grind_er...:-.,_..._.Lot,.Size_--_-__p._d.........:...<..,,:....._......._.-•-_____._ <br /> of <br /> Water Su I Public S stem and name................. ..... __ ___ Private.. <br /> PPY Y _ - <br /> Character of soil to a depth of 3 feet: Sande►• r Peiit❑ 'Sony Clay loam E] <br /> Hardpan - Adobe F7l Fill Material._ ---------If yes, type t <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�sepfic tank or seepage pit„perm;tted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK [ ] __f...�4____..(c-�Y_1 .-s o`Liquid Depth _..T..._........._r_. <br /> Ca ocit /�ov _T e . . . ...............Material__-:_C ^.:. t.-No. Compartments P Y - YP P ,_.. <br /> Distance to nearest: Well. 3_ADt_/_!_-•-.: _._Foundations....____:_._..._....Prop. Line............. <br /> oe <br /> LEACHING LINE [� No. of Lines-'___...... .._.___.•...leng31 <br /> th of each line -----------------------------Total Length..;;,_.__2-/0 _•__ <br /> ; <br /> 'D' Box..X__._.Type Filter Material:_................Depth Filter Material.........................................._._ .............. <br /> Distance to nearest: Wel l------- .....Foundation---'-------------.-_-_----•..Property Line........---------------------- <br /> '__.� <br /> SEEPAGE PIT [ ] '- Depth -... "-..__Diameter-------.-----------.Number.........;.....- -------- Rock Filled Yes ❑ No EIWater Table.Depth------------------- ----_--------- ......,.............Rock Size.....-- •----•-•--•--------•---- ----•---------- <br /> Distonce to nearest: Well...........................................Foundation..t.......................Prop. Line.-------------- ............ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_-------'----•-----------------------._--------Date---.-----------------------------------------I Y <br /> SepticTank (Specify Requirements).........................................•------------------------------------------------------------------------------- ••--•..............----- <br /> DisposalField (Specify Requirements) - - ----------------------=----------------------------------------------------=----------------•-------------- -------------------- <br /> 1 .T <br /> .......... <br /> •----.........................._............._..-�- ...............__..............._-•----...__._................-'-.-..t..........._............................................................. ._•.- <br /> (Draw existing and required addition on reverse 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: <br /> 1.1 certify that in the performance of the work fo which this permit is issued, I shall not employ any person in such manner as <br /> to beco su t tn la of California." <br /> Signed... .............Owners 7 <br /> BY - --- - --•--- -- • •-- -•----. _.Title--------- ------ -e - ._ r <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> 0 DATE.. "' ---------- '. <br /> DIVISIONOF LAND NUMBER. ----- ---_--_----•-_ ---------------------•----•-•-•..............._ .........---:-------------_-DATE........:....•-•----I-----•-•-•......---_-•y•-- <br /> . �DITIONAL COMMENTS_...... '--------------- -- --------•---------=- ........................:......I.................... <br /> ..................................................... <br /> -------------------- ---------- -------------­--- ..... .... . .. ............ <br /> . r <br /> —• _...._._._ ------------ r{ <br /> a..................... ........ -- .._.. .._----• ..................... <br /> -. <br /> Final Inspection by �.-:. .............................................................=--•-----------Date.---------•--. -- ­-------------------------- <br /> •-•--------•-. <br /> EH 13 24 ='SAN JOAQUIN LOCAL HEALTH DISTRICT PaS 21677 REV. 7/76 3M <br />