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PFOB OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ,,, <br /> �� {Camp[eteinTriplicate) ��r:­`r <br /> ------------- i ' } .date Issued <br /> This Permit Expires 1 Year From Date Issued 7" <br /> Application is hereby made to thetSan Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This iap�lication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: I <br /> JOB ADDRESS/LOCATION .-- " I . 1t.��F ---- --- `` � CENSUS TRACT <br /> ---------Phoneo 1:3 <br /> Owner's Name -j -- - -- �/ <br /> Address - -----/ia�-��� ��_�i�f1__.�i� ------------ ------------- city A ----------------- - ---------•---------- <br /> - ' <br /> License � _ Phon <br /> Contractor's Name .. _�X� ------ ---��- -------- ----------�-=----- - - ❑ <br /> Installation will serve: Residence partment House Commercial Trailer'Court ❑ <br /> Motel ❑Other -------------- ---------------------------- <br /> i r. <br /> I �--- Lot Size���- --h�C/f�F'S-� <br /> Number of living units:___!______ Number of bedrooms a2-------Garbage Grinder _.1-__-- <br /> Water_SupPIY.,Public System,and name ----------------------------------------------------- <br /> S��{ - _ Private <br /> ---- - -- <br /> - e <br /> f Peat and Loam ❑ Clay Loam',❑ <br /> Character of soil top depth of 3 feet: Sand'(Silt❑ Clay © ❑ Y <br /> (Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> � g� f <br /> s buildings, etc. must be placed on reverse side.) <br /> {Plot plan, showing size of lot, location of system in relation to wellsf N . <br /> NEW INSTALLATION: (No septic tank or seeps a pit permitted ifpubc sever is avail ii within 200 feet,) A/ R►f <br /> gg O <br /> PACKAGE TREATMENT-[] 'SERTIC TANK'[ Size-�- '---- Liquid Depth _ 4-------------•--- <br /> Material ,P/77 No. Compartments--..---•-•---=---- <br /> a a Capacity . -Qe---- TYP -- i <br /> i ' $ > ---------- <br /> Distance nearest: Well-- -----=---=- Foundation-------- ----- Prop. Lin <br /> r , de <br /> _ �] Total Length . /0-----------•-- <br /> LEACHING LINE ,[�JNo. of Lines,- ------------- Length of-reach line- J-- <br /> 4 'D' Boxy - Type Filter Mate 14r <br /> Filter Material1.17-------------•------•.---------:---- <br /> Distance to nearest: Well oC-ems-_ -------- Foundation &------- Property Line. -_-------------•-•----- <br /> SEEPAGE PIT '[ ] Depth - Diameter -- ----------- Number ---------------------------- Rock Filled Yes ❑ No <br /> 1 <br /> Water Table Depth Rock Size --------------=--------- <br /> ------------------------------------------------ <br /> I -------------------- Pro Line -------•---_--- <br /> Dis#ance`to nearest: Well / -------- <br /> Foundation P <br /> O <br /> REPAIRfADDITION'(Prev. Sanitation 'Permit# -."--------- - <br /> --------------------------- Date ----------------------------------1 <br /> fI 1 ---.-- .. -------------- - ------ <br /> Septic Tank (Specify Requirements]k----------------�------------ <br /> --------------------------------------- <br /> Disposal Field ]Specify Requirements] -------•------------------ ------------------------------------------------------------------------- <br /> ------------ ------------- <br /> { --------- <br /> - <br /> - - <br /> -- _ .. _._" __ _ - -- <br /> ;�:: ----------------------- ------- <br /> -------- ------------- ---- - - ------- - <br /> g= - <br /> r M� -----s (Draw,existing and required addition on•reverse side) <br /> I hereby certify'thdt71 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws,.and Rules and Regulations of theSan Joaquin 1:7ocalHealth District. Home owner or licen- <br /> sed agents signature certifies the,`folloWing: I <br /> I <br /> "I certify that in the performance,dfC,t a work for which this permits is issued, I shall not employ any person in such manner <br /> as to become subject to Workmas <br /> n' '. mpensation laws of Californi <br /> a <br /> i Y <br /> iSigned -----' ----------------------------------------------YOwner { <br /> a 1. T i t I eQ,&1o0V PX _k.7 --`----- <br /> ----------------------- <br /> BY , <br /> - <br /> (if other than <br /> � "t t f <br /> FOR DEPARTMENT USE ONLY . <br /> j ` <br /> -------------- <br /> APPLICATION ACCEPTED BY __:' tt <br /> r --------- --------------------------- <br /> DATEDATE .� f <br /> BUILDING PERMIT ISSUED --------9--------------------- --------------------`--�'- - <br /> ADD,ITIONAL COMMENTS --------- ------ -- --------------------------- - <br /> t --------------_----------------------------------- - - ' <br /> .________________ _ __ __ <br /> F I' <br /> �___________________ ______ -_ <br /> ---------------- <br /> i - - ---------------- odr <br /> I_______ _______________________________ _-- __ ___ ____ _ e __~� <br /> Final InspeetiQn b- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> E. H. 9 1-'6$ Rev. 5M ,� <br />