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If c FOR OFFICE USE: FOR OFFICE USE: <br /> i APPLICATION FOR SANITATION PERMIT <br /> Permit No. . y. - <br /> ti (Complete in Triplicate) <br /> Date lssued..6-,?6-- <br /> ................................. . ..... ...... -_ This Permit Expires I Year From Date Issued <br /> ----------------- <br /> Application is hereby made to.the Son 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...------......... 1.ta---- - --- -- - -----.CENSUS TRACT............... . ............. <br /> OwnerwsrName... <br /> ' *01257, <br /> -- .. . ...... <br /> Address....----��--�-- ....-- -�. -- -�/�-/..✓/.L.....------- -: •-- -�-- --�i4 y_f:. -: .CitY--- ��-----------:----...... -�"-- <br /> %'y �7�, ..- License �i57,_ .--..Phane.�+ , "S <br /> Contractor's Name.. -- `-:U- .��-<,�'` 4 <br /> I Installation viiil1'ser�e: rResidence Apartment House ❑ Commercial ❑ Trailer Court ❑ i <br /> Motel ❑ Other---....... --------------------- ••------- a <br /> Number of living units:.. <br /> -1 umber of bedrooms.�?_' ......Garbage Grinder........_Aot Size................. ...£. .......... <br /> ... <br /> Water Supply .Public System and name..... ...... .... . -- -- ................... --------- ....---....M1----------- Private A <br /> Character of sail to a depth of 3 feet: Sand ❑ Silt ❑ Clay El Peat [I Sandy Loam Clay Loam E]4 w ` Hardpan F-1 = Adobe ❑ Fill Material­_.. -.-.If yes, type...•----------_------------ - <br /> r <br /> z {Plot plati 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 [ j SEPTIC TANK [aj Size..S . _X� <br /> 217_0 a-----=----- •-- -------Liquid Depth...5,.!1/-......--------- <br /> i Capacity0'a TYP ! cGge:.r.....Matey'ial- No. Compartments---- <br /> �- 1 <br /> f Distance to nearest: Wel1-.-�1�0'"r'.- ___........-- oundation_..�d-F.- -........Prop. Line <br /> ................a <br /> F /7 t T <br /> v <br /> ` LEACHING LINE : [ ] No, of Lines._.. --------------- -Length of eacp ling.---...- Total Length ..... Q <br /> D' Box--'- ......Type Filter Material_1 ._9��Depth Filter Material--.----I-l----- ----------------------------- <br /> Distance to nearest: Well:16, __- -.:Foundation_/_o-• --------------Property Line..---- ---------`3..........---- <br /> SEEPAGE P17 [ j Depth----------------Diameter---------------�--Numberk - "E. Rock Filled Yes ❑ No <br /> I v <br /> Water Table Depth------------------- --------- -- ­---------­-----------Rock Size. --- -------------------------- v <br /> i Distance to nearest: Well-------------- ------I......... . I------Founcldtion--- ..---.,Prop. Lines - - ....... ....... <br /> REPAIR/ADDITION {Prey. Sanitation Permit#---------------------- -----------Date.....------. - ---..------------ ------.-- <br /> -----) ~ ; <br /> Septic•-Tank (Specify Requirementsj....-- ---- .... ............ .. ------•- - =---- ---- .--.....-- - -- ------ --- ----------- <br /> Disposal Field'-(Specify Requirements]........ . ------------- --------------------------------------------- <br /> - `-- ....... ....... ­------------------- ...... ------= --- <br /> µ ru t f ------- �.. <br /> ('Draw�eexisting and required addition on reverse i dej"'" "rt <br /> I hereby certify that I have prepared thls'applicatio`n 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 Lacal Health,District. Home owner or licensed agents <br /> _ r T -t � ' <br /> signature certifies the following: <br /> "I certify--that in the performance of the work for which this permit is-issued, 1-shall not employ any person in such manner as <br /> : <br /> to become subject t o :an's Compensation laws 'of California." <br /> i Signed. ,_.... '.....-_Owner <br /> it a ----------- ---- <br /> r ..... - T 1 <br /> (If other than owner) <br /> FOR EPART NT USE ONLY <br /> Y - / g <br /> APPLICATION ACCEPT7BBY ::. ............ - -DATE ...fit- -f DIVISION OF LAND`NU ... --------- ......----.DATE.---.... :..-;_. <br /> ADDITIONAL COMMENTS............................... <br /> - .... ------------ ------------------ -------- <br /> ..._.... <br /> ------------------- -----------..-------- <br /> ­­....---- .... . ..---. <br /> ---------------•-- ----.... :.- <br /> - Date...----.6 /•� �0. <br /> ............ <br /> Final,Inspection by:...............L. ...... <br /> -----•--------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/�pL�n <br /> 4 l�J <br />