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FOR OFFICE USE: <br /> *� FOR OFFICE USE: *` , . ,,APPLICATION FOR SANITATION PERMIT �•. ; <br /> -------------------------------- ------- ------------ 1 <br /> Permit No- - ------ -------- <br /> (Complete in Triplicate) `�, <br /> -- --------- Date Issued./d-_-#��"7, <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 applic ition is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ; <br /> _•"�Q ' D <br /> ' d = <br /> CE <br /> -----------_ CENSUS <br /> TRACT <br /> JOB ADDRESS/LOCATI N_-.r_- --:::� � � P ���----�- <br /> -------:--- ------- <br /> Owner's <br /> - one <br /> • �� <br /> Owner shame - �' - ;- <br /> CitY-- ' -------- ----------- Zip <br /> Address-- 4©_ _d?' �-' <br /> t } L - - - on - ---------- <br /> contractor's Name - -------- --- icense #_al S Ph e_ <br /> `] -. .,, 3 + se. Commercial ❑ Trailer Court ❑ ; <br /> Installation will serve: Residence S Apartment Hou ❑ 1� , <br /> i Y. Motel ❑ Other'-- :----------------------- --- V <br /> l k s ! 3 '__lot Size _,A - ----- t <br /> _3r,_, Garba <br /> Number of living units-- ----- Number of bedrooms ge Grinder ._'__ <br /> = Privat <br /> ---------------------- <br /> Water Supply: Public System 1and-nam e- -- � ilt ------- <br /> Clay� Peat ❑ Sandy Loam ❑ Clay � n•{ e r <br /> - -' -- <br /> ay Loam ❑ <br /> Character of soil to a depth of 3 feet.� 5aZer- <br /> S ❑ Y ❑ _ <br /> ;. . , Hardpan ❑ ` AdFiII Material - ----lf Yes,type - s <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.'rnust be.placed on reverseJe <br /> side.) y <br /> NEW INSTALLATION: INo�septic tank or seepage pit permitted if public sewer i available within"200 feet,) <br /> I <br /> $ '------- <br /> em <br /> -------------------- - <br /> PACKAGE TREATMENT'-( ] SEPTIC TANK Siz ---- --�J -qid ; <br /> �_-Material_-_ No. Compartments_f--__-____-- <br /> Capacity_. �� TYp - <br /> _ } Foundation.:, Q� Prop. Line <br /> Distance-to nearest: Well-__ _Z-------------- ,� <br /> � e <br /> i ` <br /> LEACHING LINE; No, of Lines - o_�.- ---------_ _Length of a ch Tina. lJ. - ,��-� . otal Length <br /> d---------------- <br /> .4; . ; <br /> s 'D' Box___l./--.'--Type Fllter Material_` � epth Filter Material--_'_ __ _-- <br /> ,; <br /> f Line-- -- <br /> + -----Foundatio�l ---- '- Property <br /> •Distance:to nearest: Well_:_---- -- <br /> _., <br /> 1 � Rock Filled Yes Ll No' <br /> SEEPAGE PIT [ ] Depth---- '----Diameter--------;----------.Number <br /> - <br /> Water Table Depth- ,- Rock>.Size._ <br /> --- d <br /> c <br /> e Distance Jo nearest:Wel -------------------------- ---- <br /> --- Foun ation.-------� -'- ----- '-.Prop. Line-- ----=--- ----- ---=- - <br /> # rDate------- ----------------------------------- <br /> REPAIR/ADDITION ) <br /> (Prev! Sanitation Permit#__--------------------------------- <br /> I , ------------- <br /> Septic Tank (Specify Requirements)----- ---------.-----------=------- ------------------------------- - ----------------- .. ----- =- <br /> --------------------------- ------ <br /> ----- -------------------- <br /> Disposal Field (Specify Requirements)------------ -'------._ G - s <br /> ' ,.�. - ----- .-- -- -- --- ------------ -- - - - -- ---. --------- <br /> b <br /> . --------- <br /> - -- _---'-------,a-- <br /> } -------- --- ------------------ <br /> ' -------------- -------------------- <br /> ------- t - -A <br /> i <br /> m (Draw existing'and required addition'on reverse side} ; <br /> I hereby certify that I have prepared-this and that the work will-be-clone -a--inwith .San Joaquin County <br /> Ordinances, State Laws, and Rules'.and Regulations of the; San Joaquin Local Health district. Home owner or licensed agents <br /> w <br /> signature certifies the following: t .T. - w.. . <br /> "1 certify that in the performance of the work for which this permit is +ssued,`l shall.knot-employ any person in such manner as <br /> n's_ mpensation laws of California.'; <br /> to becoze jert to Wo� €o x <br /> l <br /> __ Owner' <br /> Signed--'- '----- '- ---- <br /> � - _ ----- - ----- - - <br /> By- <br /> LJ <br /> Titl --- ---------- <br /> (If other than 6wer) .t <br /> . {�_ AOR.DEPARTMENT.USE ONLY K f <br /> t <br /> k --� ----------------------------DATE./A--�. �_�------------- <br /> APPLICATIQN ACCEPTED-B -- --- ------=--- <br /> t DIVISION OF LAND NUMBER.------------------ ------ -------------------------------------------- =- - �- _ -. _ DAT -- - <br /> . � ------------------------------------------ --- <br /> ITIONAL COMMENTS----------- -------------------------- <br /> ADD <br /> 4 ..� ________ <br /> b ___._. __-___..___.____i___________ _________ s. _ _._-___---------- <br /> ------------ <br /> ___ ________-.____-_.__-______..-___._._-_______.______-____________.___ --_ <br /> .T <br /> -------------------------------- <br /> 1F _ _____________________________________________ _______________ <br /> � -------- <br /> - <br /> -------------------------------------- ------------ <br /> - <br /> ------- -- ------ --- <br /> --------------------------- Date ------ <br /> F <br /> -- <br /> Final Ins ection b = !�. - _ `1 .-_ �'i" <br /> p Y'----"-- --`± L ------- "� F&S 21677 REV. 7/76 3M <br /> EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT <br />