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FOR OFFICE USE: / FOR OFFICE USE: <br /> /APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No "-/D.. - <br /> Date Issued_/krc,.P-_-2_ <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 Rules and Regulations: <br /> JOB ADDRESS/LOCATION --- ..------- ----__.......--•- <br /> -- <br /> -------..CENSUS TRACT................................ <br /> Owner's Name.... .... Phone <br /> Address_... <br /> ( •'!?0�� �j.... city Zip_..:. g.. ........Contractor's Name_ . 1R. -G t�� ••--------- -- - ------ ------ # j - �f_j( ------ -Phone..9.., ./ . ......... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Mo I ❑ Other-- -- - -------- --- ..................... <br /> Number of living units:-._....,-----.Number of bedrooms..'___ Garbage Grinder............Lot Size__-d /1..J ©............... .. <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 /> ......_._. <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 septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size __41 A.1- 470 .:---..--_______________Liquid Depth#---------.-..._-.-- <br /> Capacity_/- G/_....Type..,, ------ ----- Material. ------------- <br /> No. Compartments-----------••-------•--•- <br /> Distance to nearest: Well .._.1.Q r�.... .....................Foundation....._ _.Prop. Line.. ----_-_------ <br /> LEACHING <br /> ---.. -_-----.LEACHING LINE [ ] No. of Lines 9 ----.Length of each line.-..--- Total Lenvth _.t-_-°7..d........ ............. <br /> 'D' Boit' .-Type Filter Material-----`.__. o Depth Filter Material...1-T.......--.. -----__--_---_ ....._._.._......... <br /> Distance to nearest: Well----._-.-_-*----_... ...Fundation..........:.................Property Line..._----- ___---- .............. <br /> SEEPAGE PIT [ ] Depth_..IkA; ..Diameter-. ...Number- _..-O?l---------- --------- Rock Filled 'Ye s No❑ <br /> - <br /> Water Table Depth----------------------------- ------- --........Rock Size.---- I. . ..............................- <br /> Distance to nearest: Well......1.PO------ <br /> .....I...........Foundation._..---- .-__.. - _..._.Prop. Line-------- -•--_-._..------. <br /> . . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....._.........._._............. ---------------Date............._...-------_-_----------------) <br /> Septic Tank (Specify Requirements)-------- -- --------------_ -- ------•--• - -------------•--- -. ---. <br /> Disposal Field (Specify Requirements) ............ -•----- ................. <br /> -••--"-------------------- - ---- --------------------------- ........................... ................ --- ......... <br /> ................ ---------------------------------------- - ----- -------------...--------- -------------------------------------- ------ ............... <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 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 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--- -- Owner <br /> By........... -----------.Title -------- ---------- ............. -- ------ <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY............ •--•------------ ------..DATE $ • -- -- <br /> DIVISIONOF LAND NUMBER------ ------- ------ -- --- -- --- �-------/,-.....---------------------------- DATE------- ---_---------------- -------_----- <br /> ADDITIONALCOMMENTS---------- ------ .. .P/4 .�.....----------0-5.4.33.......... ------ --------_--- ------------- -------------------- ---------- -- ----... <br /> ----------------••-...... - ---------------------------------------­-----­ ---------- .............._---- <br /> ................... - ---•----- ... - .......... ........................................ --••------ - -------------•-- ----------. -------- --------- .................... <br /> -4 <br /> Final Inspection by: .. ------------ ------- - --------------------Date -•--•---....__.. <br /> ._./ _5 . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fss 21a» REV. ���a 3M <br />