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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 'ry <br /> -------�--- - -�---�-------------- -- � - ;. Permit No.�/.".��_ <br /> -. (Complete n Triplicate) � � <br /> Date Issued <br /> •--------- - ------------------------------ ------ ---.-_ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for 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 /> JOB ADDRESS/LOCATI N--. ---- - _ - _-- <br /> / - ------ CENSUS .TRACT <br /> Owners Name--------- ►- - = - = = - o <br /> - -. -- <br /> Address --------------- -.. 1 <br /> h ne �.� ` <br /> ► ------ ---- - - --- -- -- <br /> C"ty ZiP <br /> Contractor's Name-----. _ j <br /> ----°----- -------=---------------- -- 2�-� _Phone <br /> -License # .�- - -- +: <br /> lnstalla'tion:wlll serve; ResidenceApartment House.❑ Commercial ❑ Trailer Court ❑ € <br /> Y r / <br /> ;. --. .. Motel E] T Othe _ " r <br /> Number of livin� units:_ -Number of.-bedrooms: <br /> g -�-� --- v �__7. GarbageGrinde�r__._,--------Lot <br /> Water Supply: Public System and.name ---- -- - ---- ------------------------------------- <br /> -------------------------Private <br /> f <br /> Character of soil to a depth of 3 feet: Sand ❑ :Silt ❑ .Clay ❑ Peat ❑ Sandy Loam �* Clay Loam ❑ s <br /> 1 1. . <br /> € Hardpan ❑ Adobe ❑ Fill Materia!_..___.-.----If yes, type___:-------_ Y # <br /> (Plot plan, showingsize'of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: "I(N6 T <br /> septic tank or seepage pit permitted if public sewer is available within 200 feet,l <br /> #'PACKAGE <br /> .TREATMENT .SEPTICrTAN;K^-']. <br /> Size----M� - --- ----------------------- ----_----.-----Liquidt <br /> Depth------------------------ <br /> Capacity <br /> .------:-------- - - <br /> CaPacitY -- - _ --Type :_ ......... - aera ---==------------------- _No. <br /> � <br /> Compartments.------�-°---_----------"--- -- <br /> Distance to nearest: Well.:---------= =------=---=_.._.- Foundation-------------=------------Prop. Line--=------------------------- <br /> LEACHING <br /> ------------.---- -LEACHING LINE: F'------------ -----Total Length.: _ :---------- <br /> ,_ YP terial---------------------Dep4h Filter Material----------------------'------------------------------ <br /> Distances. <br /> ---- ---- ---------- <br /> } Distance to`n'crest: Well_-___ � - � # { _ - # .----- , - <br /> D' Box.-..-.-.-:..T e.Filter Ma <br /> -------'--------------F Foundation ---- _.Property Line--Y------2 <br /> SEEPAGE PIT { ] Depth.- . Diame#e -------Number_- __ _ _ ; Rack Filled Yes ❑ Nor❑ <br /> I <br /> Water Table-Depth---' -- ------- -` -- Rock Size -w <br /> - Distance to nearest: Well_.'-_--___.__------------- <br /> ---------------Foundation -------- " =------Y-Prop. Line------------------ <br /> REPAIR/ADDITION (Preva Sanitation`Permit#---------------------` :-------- -------------.Date--------------------- <br /> --------------------------- <br /> Septic Tank <br /> -------------------'---.---_-------Septic.Tank (Specify. Requirements) -------- ------ -- '• <br /> --------=----- - <br /> Disposal Field(Specify Requirements).____ - _:_ ?' <br /> -------- ---•--- ---- <br /> r � P _ <br /> --_ ------•G --- - -- - - -- ---------- -------------------- <br /> --- - G ----- ------- - -------------------------------------- ------ ---------- <br /> --------------------------------------- ----------------------------------------------------------------------------------__------------- --. <br /> _ ---- --------------- <br /> ] ;i(Draw.existing and required Addition on reverse side) <br /> hereby certify that 1 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. Sari Joaquin�toca! Health District, Home owner or licensed agents <br /> signature certifies the following l, \ s <br /> } , <br /> "1 cern that in"the ; � ° 1 # 4 j � ; <br /> certify perforMonce of the work for wh�ith this permit is issued,,l shall"not employ any person in such manner as <br /> S! bed- I � x <br /> p +� nia." <br /> to become . ect to-Wor n's C` m ensation: laws.of Califon <br /> gl ; n r # <br /> /, <br /> Y ------ <br /> 1 - ;1 Title. ] <br /> (I# other than 8wner) h <br /> FOR"DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED B_Y--------------- <br /> - - - --------- ---- - -- ------='--- -------=---- -- ---- ----------------------.DATE ----- �- <br /> DIVISION OF LAND NUMBER,--- ------'.---- -' = __ _ "` DATE = - = <br /> .., - <br /> -- <br /> ADDITIONAL COMMENTS------ -----_'�,.-�'--•----------------`-^.------=----------------------- <br /> ------------------- <br /> ---- --- '--�-----------_------- # <br /> } - -- ---- ------ -- - ------------------------------------------------ <br /> -------------------------------------- <br /> -- ----- <br /> Final Inspection b - -- - —�1'�� <br /> ---------- <br /> -.-:-..--------------Date------ --- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76�" <br />