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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT y <br /> _.-.._._------- ----- Permit No...L'.� <br /> -- _ (Complete in Triplicate) - -- <br /> - ---....-..- ' Date Issued...%�'"`�.-"7 <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 /> This application is made in compliance with County Ordinance No 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC T �U � P"".1z� ` - - .. , CENSUS TRACT __ <br /> Owners Name. � j y r�...P.h-.on-e ..Zi-p----- ----_--- ------ <br /> Address .�lV / Cy ...... - C'b� <br /> Contractor's Name_.__ _-.1.-` 'D �"C-- -- ---- - License #�� � �!-. _. .Phone.45/E.S-. ..-. <br /> Installation will serve: Residence' Apartment House❑ Commercial E-] Trailer Court E] <br /> Motel ❑ Other---------._ -------....-.-. . .. _.--- ---. <br /> : _ / <br /> � <br /> Number of living units:._../ .__Number of bedrooms Garbage Grindet. _ . Lot Size -...._.___.�-.. ---- � <br /> _....____...__....__. <br /> Water Supply: Public System and name_......---------- __ ---------------------------- --------------- ----- ------- -------.Privateo <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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I 1 SEPTIC TANK [ 1 Size----------- --------- --.........................__.__..Liquid Depth <br /> Capacity.... --- ----------Typo--- ........__---...Material--------------------------No. Compartments-------.._-...._._..... ..._._� <br /> Distance to nearest: Well-.--_---_--- - .......Foundation ..................._.__Prop. Line...... _.. ............ D9 <br /> LEACHING LINE [ ] No. of Lines-------------_..-----------:Length of each line._.-.-_---_----------------Total Length_...........____.. <br /> 'D' Box........__Type Filter Material-. -----------------Depth Filter Material_ ----------------.-------_._..-...--------- -_---_-_----- <br /> Distanceto nearest: Well..__----------____....Foundation.............. ............ Line..-..............----- ..__' <br /> SEEPAGE PIT [ ] Depth..___........Diameter._ ......_____Number___-------- ......._. ------ Rock Filled Yes ❑ No <br /> Water Table Depth.---------------- -- -----------------------------.Rock Size- ------------------- - .. E <br /> Distance to nearest: Well------------------- --------- ------------Foundation---------------.----------Prop. Line_.__ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----.___... ------- - ---------------------Date-------- ---------------- I 1/ <br /> Septic Tank (Specify Requirements)_ �--------------_- <br /> Dispo I Field IS Requirements)- - '-'------'� ----- � �' —` --- --- -- - `---r--5- - - <br /> y <br /> ------- --- ------ <br /> ..._.----------------------.......-------....----- --- -----------.. ---- --- ------- <br /> ----...._-----------------............_.-----...._..... <br /> --'-- Y --__...-------- ---------- .----- - ---------'----..------------------ --------- . -- --------------- _....._.----.._....._.... <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 worksfor which this permit is issued, I shall not employ any person in such manner as <br /> to beco bi to mans Compensation laws of California." <br /> Signed.. ...... Y ELL1 .... . - - Owne <br /> By .._.. .......... .......... --- .. ...... -- - .. - - _.... .. <br /> (If other than o e;rJ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY_........ ......... . .. . .. ................___------ ------------------------------------DATE------ _.....--------- <br /> DIVISION OF LAND NUMBER_.------- -- -------DATE-------- _...-- ---------------.... <br /> ADDITIONALCOMMENTS...._..-----._..--------------_.-----------_.._........ ........................... -----....._--------------------------------- <br /> ---------------'--------------------------------.-_ ------------------------------------------------------ ................................. <br /> .........."-'-------------'----- ----------`--------------.. <br /> -'- ------. .y - --yy ------------- <br /> Final Inspection by:...-..--.... -- Date_-.�C. _l /fcr-_--._.----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fb5116T/ REV. ]/]63M <br />