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FOR OFFICE`tSE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------- <br /> (Complete in Triplicate) Permit No. .~: _.__ <br /> ----------------- --- -- <br /> A Date Issued_ S - <br /> 4 This Permit-Expires I Year From Date issued - *- <br /> 1 .7 _ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and,install the woilr h r_eia d s gibed. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> .__ C�- -------------CENSUS TRAC ----------------------- <br /> JOB <br /> ADDRESS/LOCATION--- _Q � -- .�.l --- <br /> W <br /> -- <br /> - -- _ $ <br /> _. - PhoneOwner's -- --- � ----- <br /> �A/ % � c <br /> ZAP / j . <br /> _ <br /> Address---.-:--- ----- ----------------- -- - ------- -z4�l <br /> Contractor's Name-------- L�/`------------------------------------- --- ------------'-License # Phone <br /> Installation will serve: Residence ❑ Apartment House o !'Comm tial ❑ Trailer 4,5jnW <br /> Motel ❑ Other-- <br /> Number of living units:_____-------Number of bedrooms_-'-"- _.__Garbage Grinder./Y-__Lot Size____ 4 _________________ <br /> Water Supply: Public Systemand name________________ _ ._______..__________-_--_Private ©� <br /> } <br /> Character of soil to a depth of 3 feet: Sand Z 'Silt❑ Clay ❑ Pear❑ Sandy Loam ❑ Clay Loam­IT ❑ <br /> Hardpan E] Adobe ❑ Fill Material--_-- ----( :Yes, type-------------- -------- -------- <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 i� availoble within 204 feet,[ <br /> s^�r r <br /> r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Lz--- <br /> Ca <br /> t_�7`�'� -------------��__,___Liquid Depth---------------_____:___ <br /> -- <br /> Capacity - - --Type. - - - aterL". ------- $-- --No. Compartments---------�------------ pq <br /> Distance to nearest: Well---------- ---------- ----------Founda_tion----_---------------------Prop. Line---�----------�____-XY <br /> LEACHING LINE [ ] No, of Lines_-__� Length of each line.__._''-.__ .--------Total Length.__. >�--___,-------- - -_,___ <br /> 'D' BoPV4-sType Filter Material:AQ��--Depth Filter•Material----17.__- -------________________________--_._________--- <br /> ! Distance to nearest: Well-- �D -Foundation-/.0_.___._:' ;.-.Property Line---lt..?------------- <br /> s7.777' <br /> SEEPAGE PIT [ ] Depth--.6- -_-.-Diamete#_ -___Number----_--/____________________ ' _-__ �;Rock.Filled Yes No <br /> /. !1 <br /> Water Table Depth--- ---------- ------------------------------------------Rock Size--- = "'.�`�,,r - , <br /> t � � ff <br /> Distance to nearest: Well-_ d-------------------------------Foundation._�5r'`^�- Prop. Line---l_�~------ ----- <br /> REPAIR/ADDITION (Prev:Sanitation Pe rmit#___ _ �c�-�___________ Date-----4/- .:7-7.._._"`._) <br /> Septic Tank (Specify Requirements)---------- ---- -- -----------=------------------------------------------------ --------------------------------- f <br /> Disposal Field (Specify Requirements) 1' __-. -G __._ ,1/ ___, _____ � �� _ _ <br /> ------------------------------------------------ '' 13 { - ........ ----=-------------------------------- <br /> - ------- -= - --------------- <br /> (Draw existing and required addition`on reverse side)------ - <br /> 1. <br /> I hereby certify that I have prepared this application and that the work--will-be-done in accordance-with San Joaquin County <br /> r <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin 1cic_al Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the'work for which this permit is issued, I shall not employ any person in such manner as <br /> to become syb'ect to Workman' Compensation laws of California.: <br /> Signed----- .-- -- -_- ,Q ........:Owner <br /> By------- '- ----------- -------- ------------------------------------------- ..--- Title----------------------------- ------------ <br /> (If other than owner) ' <br /> FORD RTM NT USE ONLY <br /> APPLICATION ACCEPTED BY------- ----------------DATE./ --/3 _.- -----------_--- <br /> E <br /> DIVISION OF LAND NUMBER--------------------------------------------------------------{ DATE ------------------ -------------------- <br /> ADDITIONAL - --,------- -- - ..��- --- <br /> -- - ----- ------------------------------------- <br /> ----------------------------------- ----------------- ------------------------------------------=--_-------- ---------------------------- ----------------------------------------------- <br /> --------------------- -- ------- - - --------- <br /> Final Inspection by:. �/�' = Date-- Tr% <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7n6 3M <br />