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a <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> -- .--- � APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No_ ----------� <br /> ------------------------------------------------------ <br /> Date <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 insta�l'the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing,IZ61es and Regulations: <br /> JOB ADDRESS/LOCATION.---- -e�'`7_ l- --- --- -CENS . <br /> RACT--------------------------------- <br /> ----------- - <br /> Owner's Name.--- . --- -- - Phone-------------------------------------- <br /> Address---- - <br /> - --- ---------f-`' Cit'--- ---- ----------- --- --------------------Zip----- <br /> Contractor's Name----- �/f � -------------I-------.-License #. t a / Phone--- <br /> Installation <br /> hone-Installation will serve: Residence [ Apartment House❑ , Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------- -_. - <br /> Number of living units:---- ---------Number o/f�bedroo s � ...Garbag Grinder____._____Lot'Size_-C�"-_-________________ <br /> Supply: Public System and name f [ y ------------------------- <br /> Water Private ❑ . <br /> { } <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Mater ial------------If yes, type--------------------------iI----- <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 sey�er is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK -1F V <br /> r: <br /> [ ] �� .. Size-4--k-44t----'---�-�r�------ -`�=-�--Liquid Depth----- ------------------- <br /> Capacity_ __r }_.Type., _----___s_-_hllat ial__--`" l ._---No. Compartments-.--_-- W <br /> "' !!! --------------------- <br /> jia ---- <br /> to nearest: Well.-_/._ GY-Q-- ....Foundation---- _0-------- ------Prop. Line---16 _________--__---. <br /> LEACHING LINE [ ] Na. of Lines.-__ ________________Length of each line._"-- __--.----.-=--.Total Length -_./-- Q.-------_-----_----__3 <br /> 'D' Box....I- ----Type Filter Material----I --I Depth Filter Material.---/-- -------------------------------------------------0 <br /> Distance to nearest: Well--------------------_foundation---`----.------------------Property Line-------------------------------- <br /> p <br /> PIT [ ] Depth---4A_b- Diameter---134----------Number______"�____f_ �_ ._ ►- -�-_ ..! Rock Filled Yes { No <br /> Water Table Depth----------------------------------------------------------Rock'Size------ ----------------------------- I <br /> Distance to nearest: Well-------------------------------------------Foundation-------------------------.Prop. Line---------------------------V <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--- ,- -.-,_-- ----- ------ --_.,.Date----------------------------------------------) 1 <br /> SepticTank (Specify Requirements)---------------------------- ---------------------------------------------------------------------------------- -------------------------------------------y <br /> Disposal Field (Specify Requirements)---------------------- -------------- ----------------------------------------------------------------------------------------------------------- ---. <br /> ------------------------------------ ------------- ------------------------------------------------------------•-------------------------------------------------------------------------------------------------- <br /> -- -- - - -------------------------------------------------------- ----- <br /> (Draw existing and required addition on reverse side) <br /> 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---------- , Owner <br /> l <br /> By------------------------------ ------ ------- --Title- - ------------------------------------------------------------ --------- <br /> Ilf <br /> ------------ -- <br /> {lf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------------------- --DATE ------ - ---- ---- ------------ <br /> DIVISION OF LAND NUM .. ------------------------------------------------------------I------ --- -------------- ------------ ---DATE..-----------------_- <br /> ADDITIONALCOMMENTS------------------------------------------------- -------------------------- ---- ----- ---- ------------ -------------------------------------------------------------- <br /> -------------------------------------------------- -- -------------- <br /> ---------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- <br /> ------------------------------------ -- - - - -- ---------------- <br /> ------------------------------------------------------------------------------------------------ - ----- ----- <br /> Final Inspection by:. Date --- Vk- <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21577 REV. /7 M <br />