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n 0 <br /> r; FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ------- --- ----------------------------- --- ------ Permit No. <br /> (Complete in Triplicate) <br /> ---- -------------------- -- <br /> Date <br /> ` <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 install the work herein described. <br /> {"his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> f � <br /> f <br /> JOB ADDRESS/LOCATION_ / -C ..---.�. � �_ ----.CENSUS TRACT - --- ---- ------ <br /> ' wner's Name-------- 7_v1 - - - � '- - - ---- ---------------- <br /> ---.Phone ----- --- -- <br /> ��.�ddress---- ---------- -- --T-- _ X ---------- --- Cit �-1 <br /> - -.. Zi <br /> License Phane-------------------- <br /> U <br /> Contractor's Name------- <br /> F-nstallation will serve: Residence [!r Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------ ------ -- ---- - -- ----------- <br /> umber of living units:------_......Number of bedrooms.__..�.._Garbage Grinder------------Lot Size-_ _-..__.________________ <br /> Nater Supply: Public System and name.--------------------------------------------------------------------------------- ___.__.Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam 2�' <br /> Hardpan ❑ Adobe ❑ Fill Material_..._.------If yes, type_______________________________ <br /> k <br /> .Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> tEW INSTALLATION: (No septic tank or see age pit permitted if public sewer is available within 200 feet,) <br /> M <br /> 'ACKAGE TREATMENT [ ] SEPTIC TANK [ Size„ ____ _ ._ S <br /> Liquid Depth <br /> Capacity-Zi -------Type_ - .Material- ---- -- ' ----------No.-Compartments----m' ------------------------- <br /> / Distance to nearest: Well----------- -------------------Foundation___,y' ___._Prop, Line_____= __-_.____ <br /> _,._EACHING LINE [ �] No. of Lines._________ A'-� ' <br /> �� ______._.__.Length of each line._.______ ____ _ __________.Total Length.___��___ ---_____ <br /> D' Box--------_.-.T e Filter Material______�`.f�_____-De th'E lter'Material_._____/-________ <br /> __ ___________ <br /> YP p z <br /> Distance to nearest: Well-__-___-_��[ _ Foundation____ ' _ _-_ ---.Property L'sne._._�?F__ <br /> --- _-- - p Y -- <br /> SEEPAGE PIT [ Depth._�� Diameter..__ _ _=`__.Number- ---------- E___-----_ - Rock Filled Yes ! No❑.� <br /> Rock Size___ 1 /i -------------------- <br /> F <br /> . <br /> f (,�', Water Table Depth-----. --k�'t� - -- -- ----------- � �-----�--------------------------- � <br /> a! 1, Z`'!14Y --------------.Foundation--------1.-V'�-e-...Prop. Line----�� '---------- <br /> T Distance to nearest: WeIL.__._.__.r .__- --_ _ __ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date----------------------------------------------) <br /> iepticTank (Specify Requirements)----------------------------------------------------------------------------------------------------------------------- ---------------- ---------------- <br /> 'Disposal Field (Specify Requirements)--------------------- ---- ---- ------- -------------------------------------------------- ------ ----------------------------..._. <br /> --------"---------------------------------------------------------------------- ----- -------- --------------------------------------- ------------------------- -_ ------------ ---------------- <br /> # -------------- -- -------------- --- -- --------- --- --- ----------------------------- ---------------------------------------------------- -------------------------------------------- ---------- --- --"-- <br /> Prow existing and required addition on reverse side) <br /> � hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 3rdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or.licensed agents <br /> signature certifies the following: <br /> f­'tt'l 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 /> I” `o become subject to Workman's Compensation laws of California." <br /> ' Signed - J Owner <br /> 1 ? <br /> - <br /> / -------BY <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- - - -- ----------------------------------------------DATE..--- .7 <br /> "DIVISION OF LAND NUMBER.- ............ --- "--- --------- --------.DATE-------- ------------------ - <br /> ADDITIONAL COMMENTS--------------- ------------- -- -------- - <br /> ------------------------------------------------ ------------------------------------------------------- --- <br /> + ----------------------------------------------- ---- - ------------- -- ------------------------------------------------------------------- ------------------------------------------------------ <br /> r�~^ -- -------- <br /> - <br /> 71", <br /> inal Inspection b L -- ---- Date. . <br /> j F EH 13 24 :/ SAN JOAQU LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />