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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � <br /> -- -- - -------- -- ----- - Permit No.---��------------ <br /> - <br /> . S <br /> (Complete in Triplicate) ------ <br /> - -------- ----- <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 a permit to construct and install the work herein described. <br /> his application is made incompliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION._-'.Q1 v..� ___..___... t CENSUS TRACT---- ______________________ <br /> Dwner's Name----- ------Ir`°.� ----�----- ���� l /� ' Phone-1//_ T <br /> c - �f--- --- --------------- <br /> ---------------------- --- - <br /> 4ddress. - 6_�Q0`----- - City --------------------------------------ZAP <br /> Contractor's Name -------------- ----�_- _ <br /> - --------- -- ----License # 3-----Phone_ A6_-?6d7----- <br /> 1 <br /> nstallation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.......... <br /> Number of living units:------ ------Number of bedrooms_____ _.___Garbage 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-------------- 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 is available within 200 feet,)'-- <br /> PACKAGE TREATMENT [ J SEPTIC TANK Size.. --------.------------- ----__.._.._-._...._Liquid'Depth..__`__------------- <br /> �J <br /> Capacity-A600. ----- Type - -- Material LO_-_ - No. Compartments -------J----------------- <br /> r r C/ <br /> Distance to nearest: Well_-------_______----- __._________ --Foundation _____G -)_________--Prop. Line_t .fa__ - S_ <br /> !EACHING LINE [SCJ No._ of Lines_-___.� ___ ___ Length of each line ___ �3 -___. ._ ___Total Length_____170 - <br /> - _____________________ <br /> - /�� � �i <br /> 'D' Box-_---' _Type Filter Material__1C�4 .- Depth Filter Material____-__/_<P._ _.__:_.--_______________________________ <br /> Distance to nearest: Well __ -----------------------Foundation-----lip-_-----------------Property Line ..__ ---_-_f <br /> SEEPAGE PIT [ Depth----,7— -.-Diameter ___ _6--------Number-------------�____________ Rock Filled Yes No ❑ <br /> Water Table Depth,.------------------------------------------------ -----.Rock Size__ / -------------------- <br /> Distance <br /> -1 rri------------------Distance to nearest: Well_-----------------------------------------Foundation----/0.------------ Prop. Line_,__-5____�________- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_._.__ _ _____________________-.-____._______-Date._____.________________. ) <br /> ------------------ <br /> Septic Tank (Specify Requirements)-------------------------- ------------- _ ------------------------------------------------•-------- <br /> Disposal Field (Specify Requirements) �'6�rx �-�� �u� -.��__ _- ---------------------- <br /> ---------------------- ---------- -------- - ---- --- --------------------------------------------- ------------------------------------------------------------------------------------------------------ <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. 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 subject to Workman's Compensation laws of California." <br /> Signed - - j ;, p(y Owner -,4 <br /> BY 6 (-' """`� ------ -- -------- Title_ <br /> If other than owner) <br /> O DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ - !1/i``---`-------------------------- ------------------DATE - ------ <br /> - DIVISION OF LAND NUMBER.---- DAT . <br /> ADDITIONAL COMMENTS `-- Q:- IG �-'--- --------- a ?€ ; <br /> --------------------------------------------- ------------------ ------------------------------------- --------------------------------------------- ---� ------------------------- <br /> --- <br /> ----- -•----•----------------------------------------------------------------- ---- <br /> -------------------------------------- <br /> -- <br /> -------------------------------- •- ------- ----- --------------- --------------------------------------- <br /> Final Inspection b - - - ----------------------- <br /> -------------------------------------------------- <br /> ----------------------------------------------- Date ----�-------------- <br /> P Y <br /> EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT Fas sten Rev. 776 3M <br />