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FOR OFFICE USE: FOR OFFICE USE: <br /> PLICATION FOR SANITATIONrPERMIT <br /> -- j 7�'-- 33� <br /> .. ........... - Permit No. .......... --...-�-- <br /> (Complete in Triplicate) <br /> •� Date Issued... _ <br /> .. <br /> ......... .................................._.........._ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin'Local Health District for a_.eratr ruct and install the work herein described. <br /> This application is. made in compliance with County Ordinance No. 5 9�and ex'sting`Rules d Regulations: <br /> JOB ADDRESS/LOCATION.,;l......_t�. ?.`�_. . --- _..CENSUS TRACT.............•-----.._--- <br /> ................• ------ ----- --- ....- . <br /> ._.' <br /> : :- <br /> Phone___Owner's Name.... . <br /> Address. - "__'�..�% . . .:#- „ ' .`. L.... . ................--- City... ? <br /> Z'P <br /> .. --------- -Contractor's Name-Name_...._._ ..L ............... License #.,I . Phone... ..... ................ <br /> ..--_:__.r..._............_.. <br /> Installation will serve: Residence E3� Apartment House.{] Commercial ❑ Trailer Court ❑ �. <br /> Motel ❑ Other................ ----- -------------- <br /> Number of living units:_...... .__-._.Number of bedrooms.._.__�__Garbage Grinder--------._._Lot Size.... r._i....... .-. -.. <br /> Water Supply: Public System and name..,.... ........ ..................... --------------- ----- ... ........ --------------...............Private (� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material......-.....If yes, type................................ <br />{Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed ori reverse side.[ <br /> NEW INSTALLATION: (No_ septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT I-) SEPTIC TANK ( ] Size.-_- .x_.t _..- ` <br /> _ .............................Liquid Depth.--------------_------ <br /> w <br /> ...---- - - ------.. <br /> Capacity..f_. .. '� ...Type_.: ..............Material.-- l .--"--------.:No- Compartments_.....p"..__� _..-__-------- <br /> Distance to nearest: Well....•r-- ---------------------------Foundoton.'._ -�" - ........-Prop. Line............•..------...... <br /> LEACHING LINE [ ] No. of Lines__._..t�:....... .........:Length of each line ....... .,5................... Total Length------- -------------------------- <br /> 'D' Box..--1.--.-..Type Filter Material........ - Depth Filter Material..._._ --- -•-"•--•---------•--- •-•---------- ----- i <br /> 0 0 <br /> Distance to nearest: Well.... _ .�p-------------- Foundation..-.-_-._...----------......Property Line------ <br /> SE-EfAGf PIT [ ] Depth_ "__.�_-....Diameter....................Number.....__.."`mss ----••-------- k; <br /> �--- Rock Filled Yes ` No E]Water .Table Depth --------------------------------------------------------Rock Size..:.---�i,' ;- -.------- ---...----•---•---.. <br /> Distance to nearest: Well ... -: ---------------=------Foundation._.7. .. ..........Prop. Line-_.....-__----.----.------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------- ..............................-----Date...--- -.---.-._.---- -. -------_--• --.----I <br /> Septic Tank (Specify Requirements)............... . ----------------------------------------------•-•-------•---•------ <br /> Disposal Field (Specify Requirements)_._....... _ --•---- <br /> _.........-'pwj <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 />"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 subject to Workman's Compensation laws of California." <br /> Signed. 4 :. Owner <br /> �f ....._. .� i' r . ------------------ s <br /> r f' 4 • - Title.. --"--------------------------------------------- ------ --------------- <br />�y ... F- -.-Z1 - ......----- ---------- -- <br /> (If other than owner) <br /> FOR PAT €N7 USE ONLY <br /> APPLICATION ACCEPTED BY DATE `3 ..1 . <br /> DIVISION OF LAND NUMBER-------------------------------------------------- -----------------------------------...------------. DATE -----• -•------------------------------- <br /> ADDITIONALCOMMENTS. ............. --................•- ....... --------------------------------------------------------------­­------------------ - -- -------------- a <br /> --------------- -••------------------- <br />.............. . ...... .. ..... ._ ..__ -------------------------­-- +' ---------------------•--------------._.. <br /> Final Inspection by;----.... -"-- ---- •-----•----- -------- --- Date. 73-----•---- <br /> fas ?• v. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT CC�� �s33 <br />