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'r <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------ <br /> P `p Permit No---- <br /> (Complete <br /> o.--- <br /> {Com lete in Tri icate �R s �e y <br /> ----------------------------- .� <br /> *� � . Date Issued----�-�-7- <br /> --------------------- <br /> _--------------------------- -- This Permit Expires 1 Year From Date Issued <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 RulesandRegulations: T a <br /> ��.- .. CEN T -------------------------- <br /> JOB.ADDRESS/LOCATION.. d r -- -CENSUS ACT <br /> one--- - -- -- ---- <br /> Owner's Name. i.--- - - = _ � <br /> Address !-4, = --------------= ; - . .. _ <br /> "� .. _City. `.. �.- Zip- <br /> If .. .tom - - P ne-- <br /> Co`r tractor's Name----::,,_--- License #.. 7- -� - i <br /> : - . . . <br /> 7 . <br /> Contractor0i.> bo Address M License No. Phone <br /> Number of living units:...------__Number of bedrooms-._�__-Garbdge Grinder------------Lor size..-/_---co- ---"-- ------------------ <br /> - E]Private <br /> Water Supply: Public-Sysfiem' na d.name.- :..-_ .. � <br /> .. <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt 0 4Clay ❑ Peat E] 5 andy Loam El Clay Loam 0 <br /> ` <br /> Hardpan E, -Adobe Fill Material-__,_--'If yes, type <br /> (Plot plan, showing-size of lot--location of system in relation to;wells, buildings, etc. mu <br /> (Plot <br /> placed on reverse side.) <br /> NEW INSTALLATION: (No' septic tank or•seepage it permitted if {'bli 'sewer is available within 200 feet,) i <br /> (No' <br /> i P P p i <br /> [ ] <br /> I ] { Size.. ► - ` ---`- -- <br /> PACKAGE TREATMENT SEPTIC TANK -Liquid Depth <br /> Capacity '----- TYPe---------=---------- Material-------- _ .___a. -i-,-No. Compartments-;•---- --------------------------- Q <br /> i <br /> Distance to nearest:Well-------.i- ------------------------�- ----Foundation--=-----------= -------Prop. Line--------------------------F ; s # ! <br /> LEACHING LINE. [ l . No. of Line----------.'----------= _Length of each :._. F. Total Length ----------- <br /> LEACHING <br /> j <br /> :�.. -,..M.:D'-.Box-- -'-: - Filfier Material -- ---De Depth Filter Material----------- -------------------------- <br /> _Type - - <br /> . _ P k .._ _...r.• <br /> : ." _ -------------- <br /> Distcince to nearest..Well-- <br /> --------------------------Foundation----------!-----------" ---.Property Line----------------- <br /> , ... • y . .- <br /> ....t,.,. .r <br /> ' SEEPAGE PIT [ l Depth th--------- ------Diameter--:-------------=----Number --------------------------- € Rock Filled Yes ❑ No❑ <br /> - ------------- <br /> Water Table Depth-=-:-------------- ---------- Size•`-.-,Rock e� <br /> 4v , <br /> -Foundation--_-- - -.--"--....Prop. Line------------------- -- <br /> ,�...,-Distance-;to nearest: C._.�__- -------------- <br /> M WeI • <br /> t ` '--------------Date.------------- ---- --- 1 <br /> REPAIR/ADDITiON'(Prev, Sanitation Permit#--------------------------------- <br /> f s <br /> F Septic Tank (Specify Requirements)-- _-- -�--"-_-r----=-------- i1 i <br /> Disposal Field (Specify Requirements)_.. --- --J-------- " f _ """ "'7r <br /> S ------ - ------------ -- <br /> ------ <br /> -- .--.-. -- _ :---- ----- - - :. <br /> I ------- - ---- <br /> . -- <br /> p (Draw existing and required addition on reverse side} l <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 gas <br /> to becom ject to rkma 's Compensation laws .of. California.". <br /> I <br /> Signed-----/ 1._ -------• = Owner <br /> _ ------- --- <br /> Title. <br /> (1f other than owner) <br /> FOR DEPARTMENT USE ONLY: <br /> - - <br /> APPLICATION ACCEPTED BY. --- ----------------------- <br /> - DATE 7 <br /> a <br /> DIVISION OF LAND NUMBER.----- ------------ - ----------- ----- -------------------- ------------------- -- DATE..-- - . -------------------------------- <br /> DIVISION <br /> -- - ---- <br /> ADDITIONAL COMMENTS. Fl dr = <br /> -------- -------------------------------------------------- <br /> t ! ----------- <br /> -- ---- -------------------------------------- <br /> - - ---- --- -- - <br /> -- ----- - - - -- - - - - -6-- --------- - <br /> -----Date -- <br /> Final Inspection b • - -- - --• -----:- ---- --- �-- -- <br /> - - - - - - - - <br /> F&S 21677 REV.7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Q <br />