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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- --------------- ---------- ----- ------------ <br /> {Complete in Triplicate} Permit <br /> Date Issue0.�­._,P-."._... <br /> -----------------------------------.-------------- ------ This Permit Expires 1 Year"Ftom Date issued <br /> V r, <br /> Application is hereby made to the San Joaquin Local Health District for a pe mit to construct and.install the work herein described. <br /> This application is made in compliance with CountX Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC TION._.. .11 -- -- -- - �_---- -- ---------- ------------CENSUS TRACT. ---------- <br /> ---- <br /> Owner's Name-s-6), <br /> ame-=- � .. ! fJA Phone <br /> Address.............. /( ' Gi" ----- --- -- ---- Z� <br /> 1�� ---- -- - --------- +v ----- --- <br /> Zip <br /> Contractor's Name..__... i License #--4 5-7.x_. Phone-.--. <br /> [� - i <br /> 1 zi t <br /> Installation will serve: Residence (Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> w r� <br /> Motel ❑ Other------=------------- V`` 4 <br /> Number of livinG <br /> g units______ ________Number of bedrooms._ _._.._Garbagerind � ___Lot Size.__.__'T-^ _ ----------I___._:______ <br /> Water Supply: Public System and name------:-:-:-----.-.:->--------------------- ----- = ' � �-=----------:---_---------,_ ---------------------Private � <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ 'Clay ❑ Peat'0 ;Sandy Loam❑, Clay Loam J� <br /> + Hardpan ❑ Adobe ❑ Fill Material------------ yes, tkipe_.___`�� __..__ -___.___- <br /> F <br /> "& qtr f C V <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildin� gs ketc� must b -plac ed on reverse side.) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK fr � Size._-__ ���-_���'table within 200 feet,] Q <br /> �. ti <br /> NEW INSTALLATION: (No septic tank or.see a e it ermitfed if ublic sewer is av- <br /> p p g p I? p t <br /> - -- � ------- - 9�--Liqu id Depth------ ------------- --- <br /> Cappcity Type t"'"" Material___t__©i(�n -No. C�partments-----�----------- --------- <br /> Distance to nearest: Well._ --CPQ----------------- _Focindi ion-f_��--------- `'--Pro Line---77'x---------------. <br /> LEACHING LINE [ ] Na. of Lines.- <br /> _ +3 _ _ _L!en <br /> g�1-�th �� hri u - pf <br /> __________ th � <br /> ��d <br /> � ` --- <br /> -------- <br /> q <br /> D' Box_/ -Type Filter Materia Depth Filter Material / <br /> e �Distance to nearest.. Wel! ; _ ' --Foundation----- - ________ _ Property Linv <br /> -------- <br /> ' <br /> ...... _ <br /> __ k' . � <br /> SEEPAGE PIT Depth..�5,.._ Diameter..__.wT __.Number__7.______.______-____ Rock Filled Yes � No � <br /> Water Table Depth---------1470-------------- Rock Size 01 <br /> ' --.Foundation_-._-. _. �Q <br /> Distance to nearest: Well wr Prop. Line--..26 <br /> -------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------- -----Date------_-------.---------_._--------------------j <br /> Septic Tank (Specify Requirements)---- ---------- ------ ---------I------------------------------ ---- ------------------------------ ---- ------ <br /> Disposal Field [Specify Requirements]----- ------------ ---------------- ----------------- ---------------------------------------------------- ----------------------- --------- <br /> ------------------------ ---- -------- ------------------------------------------------------ ---------------- ---=------------=- ----------------- ---------------------------=-------------------------- <br /> -----°-----------------------------------------------=---------=---------------------------------------------------•----------------------------------- ---------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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 /> to become subjecl to Workm 's__Compensation..laws of California." <br /> Signed = -- ---- ------------------------ - - -----Owner <br /> By---------- - ------- ---------------------- ------------------------- Title--- ---- ------ --------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- --------------------------- -------- -------DATE --- -� ------ --- --- <br /> DIVISION OF LAND NUMBER- ---------------------------------- --------------I----- -------------------- DATE---- ------------- <br /> ADDITIONAL COMMENTS --------- <br /> ---- ---------- -- -- <br /> ( I -- <br /> __________________________________________________________'_..-_ �},p_.. d f/___ /Jj'�j�'-�/j�___�fX_ - • _ _ ------ <br /> ---------------------------------------------------- <br /> _ rl�i(.,� T--J--___._ ___ <br /> ---------------------------------------------------------------------- --------------------------.---------_-----_------------- <br /> -------------------------------------- -- ----- - - - ---------- <br /> Final Inspection•by:----- '? = :- bate _� <br /> -�ti�iF J <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&s 21677 REV._7/76 3M <br />