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FOR OFFICE USE: & A FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMITS p� <br /> -------------------- °1� Permit No. <br /> (Complete in Triplicate) �,.� <br /> ------------------------------------ ----- " <br /> �I� ,; � Date Issued/___/1�-.7e <br /> --------------------------------------------------------- This Permit Expires 1 Year From Dateflssued t ` <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and irfs'tall the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> Q <br /> JOB ADDRESS/LOG •._---- -- ---- -------------= -- 'CENSl7S TRACT - <br /> i: <br /> Owner's Name.:_ ` ------ ---- -- A ---- - -- <br /> ` -� � l- .. - - `---- -----City. ---------- iP- <br /> -G1•c.s� <br /> Address_ --- '-- -- ------- --- -------- <br /> : <br /> } - 'License #__3�-S_ z r 'Rhne - <br /> -- 1 <br /> Contractor's Name_, - -- -:- -- <br /> Installation will serve: Residence Apartment House. ] Commercial ❑ TrailerCourt ❑ , <br /> ---0#her_-r�--- ----_---_--_ ----- --_---==''__ <br /> Number of living units:__ -. � Garbage Grinder:-_: _Lot Size.----___.� Q��------__- ----- <br /> r Supply; Public'.System stem and name------- ----------------------------------- 1 ' <br /> sd Private: <br /> Write SPP Y� Y Num er of bedrooms'..__.' . _ '--;---=------=------- - - - -- ------ ---- ------- - <br /> Character of soil:to a depth of 3 feet: Sand ❑ Silt❑ Clays Peat ,r ; Sandy roam ❑� Clay Loam ❑ �. <br /> y Hardpan ❑ ...Adobe:❑ Fill Materfia e'sjtYpe--- <br /> -------------------------- <br /> (Plot <br /> i ----- --(Plot plan, showing size of lot, location of system in relation to:wells building's,etc.:must be placed on reverse side.) <br /> NEW INSTALLATION:" `(No'�septic tank 'or seepage pit per. itted if public sewer is available within 200 feet,) <br /> { <br /> PACKAGE TREATMENT _ ISize_- " 1: � CQ ___-_-Liquid Depth-?-- ` --------_F---� <br /> SEPTIC TANK {�}�- je . '.�7- n <br /> -------T C`p y-l- dU. A""'1. - a1{'; O •cam`----=-No. Compartments ---- "� p---" <br /> _ i <br /> a acit T MatE<ri , <br /> ' .. Distance tol)nearest: Weil _ %I _ _�__-�_ ---: Foundation -_� -© �_-_-_-----_Prop. Line- s <br /> LEACHING LINE j�}/No, of'Lin�s� Length of each,line.,____ -� Tota! Length _ lG -- <_ <br /> S <br /> Box-)----_=--:.-Type flter M�a`terial x' ---- !�WDepth Filter Material � Z- <br /> ------------------------------------------------- <br /> V_ <br /> ---- --;- -- ------ -- <br /> g �-. Distance to nearest: ell_:__--� U _-_��Foundation-____-----__- Property Line. <br /> SEEPAGE PIT Depth-!iq ------Dia meter---------------- umber_---------�______ _______r f/ Rock Filled Yes [g. No❑ <br /> : <br /> C7 -- - - :- - -- z ----------------------------------------- <br /> Water Table Depth.-_=-�-_--� --------------=------=- ___ Rock Si e: .- D A <br /> Distance to nearest: Well--Y - i <br /> r ! E <br /> Foundation:_`--�_.. Prop. Line______________ <br /> ` � ---'"-----"'"-------'--_-"-._ _ - ------F----- <br /> REPAIR/ADDITION (PrevSanitation Permit#__ ---- ------------- ------=-------flate----- -----",------------_------n-----------1 <br /> Septic.Tank (Specify Requirements)-=---:------ - ---- ------- - --- .----- ---------- ---------------------- <br /> __:_:: - = <br /> Disposal ------------------ -------- ---- <br /> ` Field (Specify Requirements) --- --- -- ---------- -----------•--------------- - ------- --------=-----_--- ------. �. <br /> l <br /> -----=------ -------------- ---- ------ ----------------- ------I--------------- ------------- ------ ------------------------------------------------ - . <br /> ---------------------------=---- <br /> -------------------------------------------------------- <br /> (Draw.existi <br /> - - - - - - - <br /> Draw.existin and required addition on reverse side) a <br /> 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 /> I signature certifies the follawing: <br /> k "I certify that in 'the performarice-of the work for which this permit is issued, :l shall not employ any person inti such manner as <br /> to become subject to rkman' Compensation laws of _California." ` <br /> t <br /> Signed.... ---- --------------- --- - ------------ ---- - Own jj <br /> ---------- ------ <br /> t� <br /> t ------ ----- --- ----- Title ,;E <br /> 1 (If other - <br /> :;;Wer) <br /> - { <br /> F Y r <br /> 4 _ FORS DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-:-- TE' <br /> DATE <br /> ;DIVISION OF LAND NUMBER.------.:--- --------- DA -------------- ------------ <br /> -------------------- ------------ <br /> ADDITIONAL COMMENTS----------- ----------------------------------- -------------------------------------------------- ------------------------------------ <br /> t <br /> - --- ---- --- -- - - ------------------ -- ---- --- --------------------------------- = - <br /> - <br /> ---- ------------------------------------------ ---------------- -------- <br /> --------------------------------- <br /> ---- <br /> -------- ----------------------- ------ti---------- -- - -------- ------- V <br /> Final Inspection b .---Date.- ------------------------ <br /> EH 13 24 P Y - -SAN JOAQUIN <br /> LOCAL HEALTH DISTRICT Fas 21h77 REV, 7/76 3M <br />