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T — # <br /> FOR OFFICE USE: - FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ," <br /> {Complete in Triplicate) <br /> Permit No.- -- <br /> ------------------------------- - - ---------- --------- <br /> Date Issued_/1.-/Y_^2,' <br /> ________________________________---------------------___ This Permit Expires 1 cY�ear From Date Issued , <br /> Application is here y�ade to the San Joaquinocal�He01 th Distri Oct for a�pertni 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: s <br /> JOB ADDRESS/LOCATION---------------------------------------- _- ,._ - _ _ CENSUS TRACT-------_-----_---.--.- <br /> - - -------- �------------------ -----=-•-• ----------� <br /> Owner's Name i - Phon'e--------------- -------- ----- <br /> - . Ci - 2 <br /> Address------ ----- --- <br /> Contractor's Name s---------- ` -----------------------------------------License #-..-------------- ------ --Phone------------------- k <br /> Installation will:serve esidence <br /> W'O ❑; Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel-M, .. .'Other-:-:------- = , <br /> Number of living units:- ____. _Number of.be' rcmms-Garbage Grinder-- Lot Size--------- ------- -------------------------- ------- <br /> Water Supply: Public System and name :.:: :: ----------- <br /> ------------------ ----I------------------s. ------------------ <br /> ----- -- ------ ---- ------- - ._Private ❑ <br /> - <br /> Character of soil to a depth of 3 feet: Sand 0 Silt ❑ Clay ❑ ° Peat ❑ Sandy Lorin ❑ Clay Loam ❑ <br /> I <br /> Hardpan ❑ Adobe ? Fill Material__...____ I# e� yp <br /> I l ; <br /> Le <br /> , <br /> (Plot plan, showing size of lot, location of.syster1 in relation to wells, buildings,'etc. Ast `be placed-op reve�sefside.) <br /> NEW INSTALLATION: ' (No septic tank =or seepage pit permute if publi ewer is available within�7fl0 feet,)' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size_____'_ ` __:.___:___:-LiquidDept___ -------------------- <br /> Ca <br /> ___ <br /> Capaaty__�_P2 0 -- -,Type---________________ ateri .- _ _- No. Compartments--------- --n ------ --__-_-- v <br /> a`i-. <br /> ! Distance to near.est: Well-------------------- .-<-- -,----Found Y n__ -_ .--------___-- _---Prop. Line- !.---- <br /> - - -- <br /> LEACHING LINE [v]" No, of Lines_ ----------------- ength of each line,--_ --..7 -Total Length __.____ -__ :.__ -_____ <br /> 'D' Box............Type Filter Material_------:----- ----Depth Filter Materia --'-----'-------------------- -------------------- <br /> Distance to nearest: Well- -----=------ ------------Foundation-----____-------- <br /> ---- ...Property__ _..Proper.ty Line--:-------------------------------- <br /> SEEPAGE <br /> --------_ -----SEEPAGE PIT Number- ___________( 3 Rack Filled Yes.❑ No ❑ <br /> _ .... .. :. .. _'. . . . . •_ .; <br /> I ] Depth ------------- Diameter.-------- -- -_ R ck Size------------- <br /> P <br /> pista'nce'to nearest: Well = - ------------ -- c� .. <br /> Water Table.Depth <br /> ;Faun a Fon- ------- ---------:_.Prop ine___.------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------ ________ Date-- ---------- — ---- — <br /> Septic Tank {Specify Requirements]-=----=- ---'--_:------=------------------------:----------------- I <br /> s <br /> - ' <br /> Disposal, Field (Specify.Requirements)------- - - - ------------------------------------------------------= --- -------------- ---------------- <br /> -- <br /> ------------------------------------------------ ------------------------------------------------------------------------------I----------------------------------- - - - ------- <br /> ' (Draw existing and required addition on reverse side) LI <br /> j it <br /> 1 hereby certify that-1 have prepared this application and that the work will be done in accordance with San- Joaqun�aunty <br /> Ordinances,' State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner'or licensed gents <br /> sig nature-certifies the following: C/ <br /> "I c rtify that in'the pelf birnance'of.the work for which this permit is issued,'I shall not employ any person in such spanner gas <br /> to become subject to Workman's Compensation laws of California." <br /> Signed,--T---------- --- --------- ------: ----- ------ ------' -------Owner li <br /> BY-------- -- Title = <br /> -- -=------ ------ <br /> w ---- ---- -- - <br /> (If other than owner} <br /> f0 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY- - r'-�"`�------------------:------------- ---- -'--- -------- ----DATE -------� / � = <br /> DIVISION OF LAND NUMBER.___. _ <br /> -------- - - - <br /> ADDITIONAL COMMENTS ----- ---- --.-- -- C4,� DATE <br /> .. <br /> ---------------------------------------- ----- <br /> i <br /> = _ = Lr ------------------- <br /> --- -------------------------------------------- -------- ------------- - <br /> Inspection by:_____ Date___ __ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />