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4 <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> " APPLICATION FOR SANITATION PERMIT <br /> ----------- ----------- ----- Permit No.--- _--- <br /> I-- -------------------------- <br /> if (Complete in Triplicate} <br /> Date Issued--.17-: <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.instail the work herein described. 1 <br /> This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> G <br /> JOB ADDRESS/LOCATION---- -1� 7 �� � J--Al-------- ------------------------------------CENSUS TRACT---------------------------------- <br /> Owner's Name--- ---------------------- -Phone---------------- <br /> Address-------------------� '` ----- -7KJ-U City --------------------------Zip------- <br /> Contractor's Name__ ____ _License #--- Z _Phone---------------------------------- <br /> Installation <br /> _______________________________ _Installation will serve: Residence Apartment House.❑ Com ercial ❑ Trailer Court ❑ <br /> Motel ❑ Other._ __ .__._.. <br /> Number of living units:------ _______Number of bedrooms----.7---Garbage <br /> 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 /> (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 see age pit permitted ifpub,lic sewjpr ji .,available within 200 feet,} CP_PACKAGE TREATMENT [ ] SEPTIC TANK [ Size_-! . _'_�'_ �__X___ �____________--Liquid Depth. <br />} , . <br /> _ <br /> • Depth.___ <br /> __/_ J <br /> Capacity__)o1QQ------Type Material---- Na. Compartments____�-------�------------- <br /> Distance to nearest: Well----- .------------------------------F ation , -- <br /> -Prop. Line----- --------------------- <br /> LEACHING LINE [ No. of Lines________ ---------- ----- Length of each line.----- _--------- Total Length.--- -� ------- <br /> ' 'D' Box--`-----Type Filter Material------5---9,__--Depth Filter Material----------j-41-"-.------------------------------------------- <br /> `'Distanceto nearest: Well------- Q___...........•Foundation ___.Pro a ty Line-------5--�---- <br /> - <br /> ---- t3-- - -------- -- <br /> SEEPAGE PIT [ Depth-r KDiameter_________-----Number---__ --____1----------------- --- p :r Rock Filled Yes Ml/'No❑ <br /> Water Table Depth �___ Rock Size__:_ _ �- <br /> p ---_�-a8 ---- 11, = <br /> 1 <br /> Distance to nearest: Well-------------- ®--.----------------.Foundation------- -0 ----------Prop. Line---- <br /> r ---------- <br /> is <br /> REPAIR/ADDITION (Pre,, Sanitation Permit#---------`----------------------. ----------------_.Date-------------------------- ---------------_�--) <br /> -septic Tank (Specify Requirements)------------------ ----------------------------- -------------------------------------- ------ ----------------------------------------- -------------- <br /> Disposal Field(Specify Requirements)_____________________ _ <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 /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne iownerL or licensed agents <br /> signature certifies the following: <br /> 1 certify that in the performance of-the work for which this permit is issued, I shall not_,emplay any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-------------------------- <br /> ---------------------------- ----- ------------------ - - ----=-------Owner <br /> BY-------- ----------- <br /> - - -- --Title---- - ----------------------- ----------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = -=----------- DATA= --- y��= <br /> DIVISION OF LAND NUMBER---------------------- --------------------------------------DATE------------:----------------------------------- <br /> ADDITIONAL COMMENTS------------------------------- = - <br /> ----------------------------­- -------------------------------.--------=-----------------•--------------------------------------------------------------------------------------------------------------------- <br /> Finch Inspection b <br /> s <br /> P Y - ----------------------------- <br /> Date <br /> iEH 13 24 SAN JOAQ IN LOCAL HEALTH DISTRICT Fas 21677 REV. r/rb 3M <br /> 4 <br />