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FOR OFFICE USE:, FOR OFFICE USE: <br /> �- APPLICATION FOR SANITATION PERMIT <br /> Permit-No <br /> P p -:.. <br /> catel <br /> .-----_ -- --- -•---- <br /> -------- <br /> (Complete an Tri li <br /> This Permit Expires 1 Year From Date Iss�led_.:. .V, <br /> f�---------------- - " . . . ...._.:_........__ p om 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 /> Theis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: _ <br /> .JOB ADDRESS/LOCATION. .f .f `+ a".' ...;�rI --... CENSUS TRACT <br /> yr ---------------------- <br /> Owner' m ..... . .... Ph <br /> Address --------------- ---- i € i = ........ City. _ Zip----• - - <br /> Copntractor shame t; ,x .. .. F-' ;.' '' *c :.F' License #. °,. . .. ., Phone___r' ._ .._ _. . _. <br /> installdtio`n will serve.. 3 4 i , Residence_❑ Apartment House ❑ Commercial ❑ Trailer Courts[]'. <br /> Motel ❑ Other-_- ..... ...... .. ..... . .. <br /> Number.-of livirig',units: ' t Number of bedrooms . ....-_-Garbage Grinder....- Lot Size. ....... --- ----- <br /> .Y , <br /> Wh ter Supply.,Public System and name:.- _:....... .._._ _ ...---. ..- --•-------`- Private d <br /> Character of soil to a depth.of 3 feet: : Sand [] Sit Clay❑�-'Peat'❑" "Sandy Loam'❑ Clay Loam ❑ <br /> I�a•rdpon ❑ Adobe Q Fill Material--_.--.... -If yes, type..........------- ----- ----- <br /> ' (Plfl t4an, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No-septic tpnk o'r seepage pit permitted if public sewer is available within-200 feet;) <br /> ,PACKAGE TREATMENT ( ') --SEPTIC-TANK [ ] Size.......-------- .: ...... .. .,--------- ...... .....Liquid Depth ._.._ ... .. <br /> Capacity--=L.... "( Type_.;"•-------•..........Material...... . .. . -------- No. Compartments. ...... ------ <br /> ' Distance to )e'arest:'Well ion, .'.Prop. Line -J-- <br /> -f L . .....Foundat <br /> 'LEACHING EACl11NG LINE [ No. of Lines.`.'... a .------.- .`.Length of each line ..-- _. . . _ ._Totdl Length ---., f---.... T-- ...... <br /> =1 M .._.. - ------ -------- <br /> D Box':r Type, Material � . -`��.. Depth Filter Material 1 <br /> - a •".. '~ ,r" 'qct �1..�.3 �n . .___.. <br /> S' -- Foundation. ..:.:..r Property L <br /> Di stance to ..nearest:.Well----�"_--�'--....._ - �- - ` �f� ............" <br /> d t <br /> I' SEEPAGE PIT ,[ `F Depth • - - ...... -^: R Fi . <br /> Diameter.. Number ._._...., :. Yes ❑+� No ❑ <br /> �. ?a F Rock?S e <br /> r Water Table Depth---- ..__.. ........ iz ".. ,_... <br /> Distance to nearest;-Well-'_,..!.. 3 ne <br /> F anon . .-_.Prop. Li <br /> r . ..---_...-. <br /> ' I2E>�AIR/ADDlTION'[Prev. Sanitation Permit#. .... .......................:... . •-'-'-- <br /> rg <br /> epticTank (Specify-Requirements)-- - --- -- ----- ---------- -------- ----- ;.. <br /> S f� t t ' <br /> F ; p (Specify quifements) _ r I r <br /> --- . <br /> Dis osal,FieldRe � -- .................... ----- ---- ------- <br /> --- -------------- - ------ -------- ....... - ............. .. <br /> ..!'..- .............---------------4.>..----------- ------ ................... -......___.- ........ <br /> .... <br /> ' (Draw existing orad required addition on reverse side) <br /> !'hereby. certify that I have'prepared this-application and that the work will be d"ane in accordance-with-San Joaquin- County <br /> Ordinances,3 5tafe Law's, and Rules and Regulations icif the San Joaquin Local Health District, Home owner or licensed'agents <br /> =s'i'gnature.certifie', `the following: <br /> 4 certify that ins 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 Workmon'i Compensation laws of California." � T <br /> , <br /> Signed -----._.. ............ <br /> ,1 Owner <br /> �Ej r - ---- .. <br /> ....... . . <br /> .... ... ... ....... ... <br /> Y <br /> ) 1 � �, T +�• (If other -than owner!••-. <br /> ` - OR,;DEPARTMENT,-USE ONLY <br /> _ _ <br /> "§ APPLICATION ACCEPTED BYE 7 + `" °` `' r_'.-•--- - ----- ---- ------DATE ..... <br /> A <br /> . . - - -- =" `y,,, t '' DATE --- <br /> D'IVISiON'OF LAND NUMBER . .--•_-.-. -... " _ <br /> t ADDITIONAL COMMENTS'--`_.. .. <br /> z . ------------ <br /> ._..__ _ - Y <br /> y.. <br /> ..__.. .. ..............- - `-`` <br /> - __...__... <br /> _npc� <br /> Me <br /> ------ ... ...Date _.__ <br /> 21 677 REV. 7/76 <br /> y E:iis 24 _ -�,J E SPtN_JOAQIIIN LOCAL HEALTH DISTRICT <br />