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r <br /> yFOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> (Complete in Triplicate) Permit No'.l..!. <br /> This Permit Expires 1 Year From Date Issued Date Issueds'/r .`... <br /> i <br /> IApplication is hereby made to.the SanJoaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in complionce with County Or 'Hance o. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA�ION. ... .1.- ......- <br /> I ... .... ------ ....... ............. <br /> Owner's Name :.--- --'-- ......... ----....CENSUS TRACT..................' ...... ...- <br />` _ <br /> -- <br /> Phone....:.............•---"- --..--...... <br />' Address.. :-��_- -. ..,. <br /> r, Y... Zi <br /> Contractor's Name.__ _. ... " <br /> --- -- 'License #.c �.. .....�� .._Phone. ., __�'2..Qj_7.�i�-. <br /> Installation will serve: Residences Apartment House ❑ Commercial [] Trailer Court ❑ <br /> Motel ❑ Other <br /> Number of living units:----------.------Num ber of bedrooms.__.....Garbage Grindar.........-__Lot Size__...__........ .:...:. . r <br /> Water Su <br /> pp y,:,;;Pub'Eic System and name.- <br /> '---- <br /> ----------- ---.:." .-- _ <br /> z� --- ----- -- ------- ---- ----------•--.-.._ ... . <br /> Character`of'soil to a"'depth of 3 feet: Sand Silt Clay Private ❑ <br /> ❑ ❑ y ❑ Peat ❑ Sandy Loam [] Clay Loam ❑ <br /> Hardpan ❑ ,Adobe ❑ Fill Material.. . <br /> if yes, type.......... <br /> _......... ' <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 sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK <br /> ) ) Size.-... -- --' Liquid Depth...... ----- <br /> Capacity .Type_.....-.----- -.....Material-- ------------ ----------No. Compartments-.---= 'J # <br /> Distance to nearest: Well..................... ..'--- -'- „ Foundation_____-'.-- ' --- ' <br /> .... ...Prop. Line---............---'------'CO/J <br /> LEACHING LINE [ ] No, of Lines " ' <br /> -c:._.. == :Length�of each-line Total Length ' ' " ;._ <br /> D' Box.-- .--.Type Filter..Mdterial.._----- -----------Depth Filter Material-- .__.._...-- <br /> f <br /> ....---- "--- -'--- ...--•-- <br /> Distance to nearest: Well_:.:_..'........:.... .......Foundation.---------------,--'-- --..Property Line.............-------- <br /> SEEPAGE PIT <br /> Depth--- ........:. .Diameter------------------ _-Number.------------------- Yes <br /> Filled Yes ❑ No ❑ <br /> Water Table Depth. <br /> __--_---- <br /> --------- ---------- Rock Size--------- --------- <br /> f S <br /> ----------------D•stance to nearest: Well._ <br /> .. - ---'- - -----------Foundation-- ------ ----------- ---Prop. L1ne---'- - ------- -- ' <br /> REPAIR/ADDITION'(Prev. Sanitation Permif#--------------:._ <br /> ». . ------- --•--Date----------------- ----- <br /> Septic Tank' (Specify Requirements),-.:-_... ...... ........ I. <br /> = I <br /> Dispo sol Field'{Specify Req'uir' nentsl- ': I.C. " " - ' <br /> ..-- <br /> == - <br /> yr ----- ------------------- .... <br /> -- ...--'-- -- ... -----------•---•--- ----- <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 <br /> performance of the work for which this permit is issued, I shall not employ any erson in such manner as <br /> to hero ub'ect to War an's C mpensation laws of California." r <br /> Signe By. ---- -- <br /> " - --'------------------ ....Title--- . �.. <br /> (If other than owner) <br /> - -- F R EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY._. _--- -" - <br /> -... -- -----------------------' DATE -------- <br /> DIVISION OF LAND NUMBER.................... -"---. <br /> .._.--------'-- - ......-....' - ----------- DATE............ <br /> - --.....- • <br /> ADDITIONAL COMMENTS------- ...........:. ' <br /> --------- -------- - __..._..... ' <br /> - �- ----------------------------------- -- ------------- -----------------'---------- ------------- ---------- <br /> ...... .... . .... <br /> Final,Inspection by:.. 1 <br /> --------------------- ---Date --.� -- �7 J.. ......._.... ....... <br /> EH 13 sa 'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F8S 21677 REV. 7/7¢ 3M <br />