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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT .it <br /> , r <br /> ------------------------------------------------- - --- (Complete in Triplicate) Permit No.--- <br /> c <br /> ----------- Date Issuedv.r1_- "q- <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/LO( TION---- © J�O I -=------ -��: <br /> CENSUS TRACT- -- -------------------------- <br /> Owner's Nome---- ------ ---------------- -------------- -----------------..-------------------- <br /> Phone --- <br /> � --- <br /> zip---5-4 Z <br /> Address _. ► L/.,- - -- - - --- --'---------- ------ ---CitY 6L-c.,i - ►��o-.� rt ,---Contractor's Nam ---- 7" -4 ' _-.License ' <br /> #-_� 8--gn19a---Phone-------- ------------------ --- <br /> Installation will serve: Residence Apartment❑oteHouse E] Commercial E] Trailer Cc gra ❑ <br /> fi - <br /> Number of living units:._- "-----------Number of bedrooms---._, .,:---Garbage Grinder-------------Lot..Size---------�-....._---------------�--------------------------- <br /> IN <br /> Water Supply: Public System and name-------------------------- -!i - ---_-----------.---- -----Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt 0 Clay E] Peat E] Sandy Loam Clay Loam E] <br /> j Hardpan ❑ Adobe ❑ Fill Material._._- --1-If yds, type-------------------------------- <br /> {Plot plan, showing size of lot, location of system in relation`to-wells, bui)dings, etc. must be placed on reverse side.] <br /> NEW INSTALLATION: (No septic tank or seepage ;pit 'permitt'ed if public sewer is available within 200 feet,) / Q€ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [� Size"w _ -/ --- -- ----- ---------------------Liquid Depth.__. --------------------- <br /> --.=Mat <br /> -__-__-------- ---- <br /> Capacity.-.�ga'2-----Type- "` Material :.t 4�^--------No. Compartments -------- -------------- <br /> Distance to nearest: Well---_-------,�tp_� -- `.f.:Foundation.___-10 --.-------:Prop. Line--_-r- "------___--_ <br /> LEACHING LINE [ No. of Lines-------- ----.---:------ Length of each line.------�---------------------Total Length.-.----�-�Q------:-----------------(�, <br /> fat F f N � v <br /> 'D' Box..... _-""Type Filter Material--.-- - ----:-Depth Filter Material--------- -.---------------------------------------- --- <br /> r / <br /> Distance.to nearest: Well-:-- --1�.f""----. ..Foundation'-------�-----------------Property Line----5--------------------------{� <br /> SEEPAGE PIT j ] Depth---- --_---Diameter--------------------Number---:------9---"s----------------- Rock Filled "Yes ❑ No ❑ <br /> Water Table Depth------------------------ --------------1- '-Rock Size----------------------------:-------------- -- <br /> Distance to hearest: Well----------- ----------=------ ----------- Foundation-----------------------_-.Prop. Line-------- ------------------- l <br /> REPAIR/ADDITION (Prev, Sanitation Permit#---------------------------------=--------- ----- -- -] <br /> SepticTank (Specify Requirements).---------------- ------------------------------------------------ ------- ----------------------------------------- ------------------------- <br /> Disposal Field(Specify Requirements)------ --- ---------- , <br /> { - ---------------------`--------------------.- -------------- ------- ---- <br /> ------------------------------------------ - <br /> ------------------ - -------------------- -------------------------------_----------------------- ---------------- --- <br /> (Draw existing and required addition1ori reverse side] <br /> I hereby certify that I have prepared this application and that the work will,be done in accordance with San Joaquin Count:;, <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin'Cocal Health District. Home owner or licensed agents ¢ <br /> signature certifies the following: is <br /> "I certify that in the performance of'the work-for which this permit is issued, l shall not employ any person in such manner as <br /> to become subject to Workman's. Compensation.-laws of California." a e-' <br /> iSigned--------- --- -------------------------- --- . wnsr . <br /> j- -- --- =------------------- ---"------- 1[� €' <br /> Title <br /> ­4f-other-than — <br /> FOR DEPARTMENT USE ONLY. <br /> 1. ' ,;' 4-�_ =5?" .---- DATE.--.-- -r-_2.7*s--2��---------- <br /> APPLICATION .. <br /> ACCEPTED BY_---- -. �Y1=� - - <br /> kDIVISION OF LAND NUMBER.---------- -------------- �''�:." _. DATE <br /> ADDITIONAL COMMENTS--------------------- ------------------------------------------- <br /> it <br /> ----------i <br /> F --- ------- - 7--­-; ---------�----- ----------------- <br /> ' ---------------------------- - - - -- ------ <br /> -- --- <br /> Final Inspection b Date---- --------- <br /> 1 EH €3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/7h 3M <br />