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e FOR OFFICE',USE; <br /> i. ,FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....- Permit No. <br /> - <br /> (Complete in Triplicate) <br /> � - , �., �, .� ", � Dare <br /> .........:.....------. .........................��. This Permit Expires.I .Year From,Date Issued. 3 ,� <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 compliancexwifh County Ordinance No. 549 and existing RuleadReguI s: <br /> JOB ADDRESS/LOCATION. ..._. ?. -CjJCJ--__---" -- <br /> " ---------.LENS 5 TRACT... <br /> Owner's Name.-..... .f. Phone.... <br /> Address----------- --- -------- --! .� ... City.. Zip " <br /> r <br /> Contractor's Name.. ----�-----U -t/4�p-Q--.__�......-�-�................. ---License #�!F-.���-r-�--- Phone ;J-`-.- --- ----�' <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ 4 <br /> } <br /> '. Motel ❑ Other------ =------- ---- <br /> Number of living units:........_-.."-Number of bedrooms... Garbage Grinder-- ....Lot Size--.-f <br /> :._.... - Privat <br /> Water Supply: PublictSystem and name. - ------------------ "" ........... .-- -....-- ------ -- ---------------------- <br /> Character_of soil to a'depth of 3 feet: ; Sand ❑ Silt ❑ -Clay ❑- Peat [J Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe F1Fill Material. :�'. If yes, type-------------------------- <br /> [ <br /> (Plot plan`, showing size of lot, locationvof 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 sewers available within 200 feet,) l •v 9 <br /> PACKAGE TREATMENT { } SEPTIC TANK ['J-1' �ize.._ ,-� - ----- -------- <br /> Capacity <br /> ---" -" ---L'squid Depth. .-------"""--� <br /> Capacity...- :C' a_-.-.-Type" 1P. !.....Material....- �` s'1'G No.. Compartments---.�_,. <br /> r - 1 <br /> Distance to nearest: Well-....-- ........Foundation Ilk` <br /> Length of each line. - ... Notal length _ ... .-.. <br /> LEACHING LINE [trNo. of Lines..:....... ..---.----.-- " / y {t <br /> D' Box,IV6`.Type Filter Material--_ - Depth Filter Material------- {�........... .."... ------... ------- <br /> earest: Well---- - Foundatio -...1- ----------------4a.perty Line..--.-aal L..-----Distances to to n ,Diamete . .__ -. Number.-__:_- Rock Filled Yes <br /> SEEPAGE E PIT [j� Depth--------- ... --------- <br /> `t --.Rock Size.- -..:�:: . - - <br /> Water Table Depth------------ -U.---- -�-�- --..." - ---- - / �" , <br /> k t <br /> Distance to nearest: Well------ _ . ------Foundation--- -------...__....._.Prop. Line..------- <br /> . . ' [ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--1- -------------------- ----- ------------_Date....------•--------------- ) <br /> Septic Tank (Specify Requirements)------• --------------•---------- ...... ----------- ------------ ------------ <br /> Disposal Field.(Specify Requirements)'-------- --------- - -------- ---- -----•------------- <br /> 1 1 <br /> t -----•------------------ -----------------------•-•---------- <br /> ------•---- ----- .................... ----------------------- ----- ---------------- ---------------- ----------- - ---------­­.......... -------- ------- ------ <br /> (Draw existing and required addition on reverse side) a <br /> I hereby certify that I have .prepared this application and that the work will -lie done in accordance with San Joaquin County } <br /> I Ordinances, State Laws, and Rules And Regulations of the`4San J'oaquin`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 yshall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> t <br /> Signed-------.-- Ownex h <br /> ' - - " <br /> _ Tide -- ------ . <br /> BY ------ <br /> ( f other th n owner) <br /> FOR D-� E�RTMENT USE-ONLY <br /> APPLICATION ACCEPTED BY----_...--- ....... <br /> - - <br /> 'DATE - ------ -� / 7 <br /> DIVISION OF LAND NUM BER........ .. .. . :. ...". . _ ---------------- .... . }.DA; . <br />' ADDITIONAL COMMENTS- ------------- ---- -- ------------------- _-.. <br /> t -------i--- ----------- ........ ... .......... <br /> i ♦ .......................... <br /> .....-- <br /> ------------------ . _.- ....... --------------- <br /> ......... ......--....-" <br /> If.-..--. ----"---------------- ---------------"-- ----------------...__.--- - - -V�-..-/ <br /> . - .. ._.......... <br /> Final Inspection b .......................................... <br /> = ---------- ----Dat ---- F& �� <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT rss 16 ����3M i <br />