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�w <br /> FSR OFFICE USE: FOR OFFICE USE: 1 <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- <br /> (Complete in Triplicate) Permit No.- '� - <br /> r.",`4. - Date Issued,57�c-A r77 4 <br /> .......1-1.............................. ........ This Permit Expires`1 Year From�Date'lssued <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 ex,stin Rules and Regulations: <br /> JOB ADDRESS/ ...._.. ....._ -: CENSUS TRACT.. .._ <br /> On <br /> elo <br /> Owner's Name... ...... . .- ...Phone. ��"". . <br /> Address. .! .... - ---- - --. <br /> -- --1���-.... --�!----- - -- - - -... `.City -- .- - - - -zip ---------------Name--...... ----=--- - - ----- - • ....License #3 1-��.._.Phone.. /V <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ f <br /> e Motel ❑ Other........................ .......... ---------- <br /> Number of living units:.____....Number of bedrooms... ..Garbage Grinder----------:1ot Size.. G'�..�.-.' e: ::. <br /> Water Supply: Public System.and name....... ... ........................ ------------------------•------••----- --...---....----------------------Privat <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......................... ..... r <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) `•� <br /> F <br /> NEW INSTALLATION: (No septic]tank;or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [;] Size------- ------------------------------- .-_-..----------Liquid Depth.---:------- ------------ <br /> € <br /> Capacity.... _....._ -------,Type............. .........Material- ----- ----------- .:.._No. Compartments.------------ -._... <br /> ! Distance to nearest: Well...........................................Foundation............. ......... .. Prop. Line.--.--------------... <br /> LEACHING LINE [ ] No. of Lines.......-------- ------.Length of each line------------t.;............... Total Length -- .-----.-----------------........... <br /> i <br /> 'D' Box-----"'- -Type Filter Material......!. .:....:....Depth Filter Material..-.--------------------------------------.---,-----.--------- . <br /> 4 Distance to-nearest: Well....................t.------Foundation-----:------..--.-.---------Property Line----------:---.---------- <br /> SEEPAGE PIT ( ] Depth----....."­iDiameter----....------- ....Number ..........:.:............. Rock Filled Yes ❑ Na <br /> Water <br /> Distance ato) nea�p esh: WeIL ... .. .. Rock Size <br /> ... ...... .. <br /> . <br /> . <br /> . <br /> . <br /> . ..... ....••.Foundation-- ................ <br /> - -' ......Prop. Line....- <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) r <br /> I 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, 1 shall not employ any person in such manner as <br /> to become subject t.d, s ompe[�sation laws of California." <br /> -:-. <br /> Signed---- ------------ f��.- 1... ...Owner <br /> BY-•------ ..............---------- Title.._. .-... :..-. <br /> .. <br /> (If other than owner) <br /> 4 - FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-..:. ... - - .. . ........... <br /> --------- ----•---- ....... -----------------•- ------------------DATE --- -------- <br /> DIVISION OF LAND NUMBER C_7 - ------- --------- --------------------------------------- DATE........:.................... ........... �I <br /> ADDITIONALCOMMENTS- --- --- - ------------------------•-------------------------- ---------------------------------------------------- ............-................. <br /> ................ <br /> -•----------------------------------------- -..........------------------.................--------------------------------------------------------------------------------- <br /> -------------•-•--------------- - -------- <br /> Final lnspe6ion by: l-1�-- ----------- - -------------------- -- --- Date.... ... , <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 21677 REV. 7176 3M t <br />