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FOR OFFICE USE: ✓ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- �'-x'_7.7 <br /> 4�n �--------------- ---- (Complete in Triplicate) Permit No._. <br /> ------------ ------------ <br /> Date Issued_,/D'll'7r <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 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/LOCAT ---w Q----�--�-------------------------------------- ------------- <br /> - ---------------CENSUS TRACT------------------------ <br /> Name.. O'7° - ��kione-------------------------------------- <br /> LP 3-24?2­24- <br /> ----------------- <br /> -- ----- -------- --- ----- --------------_Cit --------Zi <br /> Contractor's Name------------------------------------- r - -- - ----------�----- - - ---License # �_2e� �1 s��_Phone <br /> Installation will serve: Residence❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> l Motel ❑ Other--------- ---G+ <br /> Number of living units:-----I_________Number of bedrooms------j_'_'_Garbage Grinder------------Lot Size-------- <br /> -------------_-___________ <br /> Water Supply: Public System and name----------- ------------------------------------------------------- - -------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand E] Silt E] Clay E] Peat[:] Sandy Loam E] Clay Loam E]Hardpan ; Adobe❑ Fill Material------------If yes,type_____________________________ <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 see ge pit permitted if <br /> public sewer is available within 200 feet,) "- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size__W__f __ ''�-r--- -- 4 ............._._______Liquid Depth_---- _____--- - ------ <br /> Capacity_l.,;Zpip_-----Typ 4.-e. 4+^- _Material___-__40 ---No. Compartments___.__'________._ <br /> ------------- <br /> Distance to nearest: Well--_. ------ 'r' __�_______________.___Foundation------- _�_ �____--_-Prop. Line______-�_-_________-. <br /> i <br /> LEACHING LINE [ No. of Lines___ .2—__________________Length of each line._______-___.-----------Total Length _____k_o--It_------------------------ �. <br /> 'D' Box----_ -----Type Filter Material-----S-A-----Depth Filter Material________ _ ------------------------------------------- In <br /> 01 <br /> Distance to nearest: Well-------+6l2____._--___Foundation-______1p--____-_______Property Line___________ ___.. <br /> SEEPAGE PIT [ Depth__ S___._Diameter_____-g_ ----_.Number__-.________ ____-- -_-- Rock Filled Yes--- <br /> No ❑ <br /> �� <br /> Water Table Depth -�1l1_ --�------------------------Rock Size---� - <br /> i <br /> Distance to nearest: Well---------I-aQ_--___--__.___.------Foundation------/___O_....._____.Prop. Line_____--_-.__ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_______________-__- _._--_____-----.Date-------------.--------------------------------) <br /> SepticTank (Specify Requirements)------------------------ --------------------------------------- --------------------------------- -------- <br /> DisposalField (Specify Requirements)-------------------- - ------------------------------------------------------------------------------------------------------------------ ----------- <br /> ------------------------------------- ------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <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, I shall not employ any person in such manner as <br /> to become subject to Workman's Co ensation law of California." <br /> Signed-------------------------------------- Owner <br /> BY - - - - --------Title--- - ------ ------------------------ --------------- <br /> (If other than owner) <br /> y� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- --- �/ DATE. d= -$ <br /> DIVISIONOF LAND NUMBER------------------------------ -------- --------------------------------------------------------DATE------------------- ------ <br /> ADDITIONALCOMMENTS--------------------------------------------------------------------------------------------------------------------- ------------------- -------------------- ---- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------- - ---- ----------------------------------------------------------------------------------------- ------- ---------------------- <br /> FinalInspection bY:------ -------------------------------------------- ------ ----------------- --Date.-- -----------I---- <br /> EH <br /> - --.---.--- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />