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} FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................----------------- -.....- <br /> ► [Complete in Triplicates ...... <br /> No. .- 3.3-. <br /> - <br /> ---------------------- --------------- <br /> f. Date Issued-2.: K.:2.. <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 /> - -----------..CENSUS TRACT............................ <br /> JOB ADD.ESS/LOCATION.--.... �...Z'�' `r�. % �: - _.fi. :-..---- <br /> i Owner's Name..... 71 A....... -� f- ti . .'..`.:.".-". .... '..-...Phone-------------- <br /> ------------- <br /> Address--------- ------ ;f=' M "� = . . City.,.-I,�14 1 Zip.-... -- <br /> Contractors Name..... -.. �...+:.' i�.�- - w- License # -off.,_Phone-.r,5. �. .... <br /> Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court Elk <br /> [ Motel ❑ Other---- -------- ----------------------------- <br /> Number <br /> ---------------------------Number of living units:.-.-...........Number of bedrooms x-....Garbage Grinder_..-- --Lot Size------ .'.- .........-----............. <br /> Water Supply: Public System and name------..........................................................................:..................-... --------------Private. <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......................... ----- <br /> 1 <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 ovailable within 200 feet,[ ' <br /> l r-•, r � -U //� <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size , - ----------------Liquid Depth._t -y-T-.. .---_._-.-- <br /> acit <br /> P Y. Type.�fi� aterial. No. Compartments__ <br /> Ca <br /> /,�- . --- <br /> Distance to nearest: WelL:..-� ._ .............Foundation..,�L7. . --.-.. __,...Prop. Line—CF-0...:-.....-.... <br /> LEACHING LINE ( ,] No, of Lines ._._ .................Leng'throf each 1ioa._ A ---------------- Total Length ....4� ...... , <br /> 'D' Box..Z....Type Filter Material__ � Depth Filter Material------- -- -�---------------------------------- ---•• <br /> Distance to nearest: Well-ffl�'� ....... <br /> ...Foundation---v` ... ...Property Line.-+�� -. ..-----. <br /> SEEPAGE PIT [ ] Depth.sr ......Diameter.� .........Number.. --- i Rock Filled Yes ((�No ❑ <br /> Water Table Depth--------------------------------- Rock Size------ .......... -'-- •--------------- 1 <br /> t Distance to nearest: Well--------------------------....................foundation-----------...........:...Prop, Line-- .........-..------- <br /> REPAIR/ADDITION <br /> --- -REPAIR/ADDITION (Prev. Sanitation Permit#.............•:.-:---------------...-. ....._.-:---.Date :,-..:.----------- <br /> -_= -----------1 <br /> Septic Tank (Specify Requirements)---- - ---------4----- ; --- -•----..............- --------------- ------ <br /> Disposal Field (Specify Requirements)...................... -: ------------ ------------------------•------ <br /> I ---------------------------------------------- ----------- -- - -------------------- ..----. ........--.-. . ----------------------_. ----------------......-..------------------ <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 /> FOrdinances, 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 performancefof the woirvfor which this permit is issued, I shall not employ any person in such manner as <br /> to become suble t�orkma 's Compensation laws of California." <br /> rt <br /> ss <br /> rt <br /> .,Signed.- .. I i�,�. : 1 .--...-- - -- -- - -- Owner <br /> . w,.-�.-- .,4. <br /> BY <br /> s. .....Title.---- -- <br /> i -•- ---------- ----------------------------------------------- <br /> k (If other than owner) <br /> ' 2 R PtPARTMOT.USE ONLY � <br /> APPLICATION ACCEPTED BY = DATE.--- 1. .. <br /> DIVISION OF LAND NUMBER.....--- ---- ..... - --- DATE <br /> ADDITIONAL COMMENTS- ---.._.. ` _ ........... .... <br /> ------------------ -------------- <br /> _ e �.- - -.. ... R .. .. h,. <br /> ........... ........ --------- ....... ----------E................... ------- . --- <br /> _--------------------• -- ------------------------ -- ----------------• -....-........ ----------- <br /> ---------------- <br /> �---- ---------- <br /> .-.. <br /> .�`� G �( -------------------------- Date_. ,r <br /> •Enspect�on by.. � ------------- <br /> Final <br /> k .. <br /> Ess 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT iikS 21677 REV. 7/76 3M <br />