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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- -------- <br /> -------------- <br /> (Complete in 'triplicate) Permit No..�-.�.- _. ...... <br /> --------------------------------------------------------- <br /> Date Issued- <br /> -------------------- ------------ -------- <br /> ssued--------------------- ----..---.--.-.----._ This Permit Expires 1 Year Frar>> 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 Or inance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO --- <br /> J L�;�_�7-------- --G _ ----•' - <br /> � - ------- ------CENSUS TRACT------------------------------ <br /> IE uJ - Phone-------------------------------------- <br /> Owner's Name--------- -------- ----------- ----------- <br /> Address <br /> --------- <br /> Address--- - -- ----- Cit - <br /> Zip <br /> I #--._ .-- Phone---------------------- <br /> -- ---- <br /> Contractor's Name------- s - --- .L <br /> Installation will serve: Residence❑ Apartment House❑ Commercial Trailer Court ❑ <br /> Motel ❑ Other_ -- - <br /> Number of living units. Number of bedrooms-.___Garbage Grinder.-----------Lot Size---- -eE- -_ __.-_.___-..__. <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 E�� <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 seep ge pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size- _f _ ______________Liquid Depth------ ____ ___ - <br /> Capacity_ a------Typep- .-Material�_A�---------No. Compartments.—'------ <br /> ------------------- <br /> Distance to nearest: Well.___------ _`--------------------------Foundation_____/.O_--- _-------Prop.II Line_____1____._______-_: <br /> r LEACHING LINE (� No. of Lines_________"_______________Length of each ling_-_-_.-�D------_-------.Total Length --------.-----______ <br /> 'D' Box..../-_---Type Filter Material-----,5 ----Depth Filter Material--------- - -- rr----------------------------------1 <br /> r <br /> Distance to nearest: Well------- --_-------Foundation------_ -- --------Property Line---------.,j--------------- <br /> . <br /> S€-E�W Depth------.�C----D auter.7-- f .Number------------/---------------- Rock Filled Yes [ No;❑ <br /> Water Table Depth--------------- --------------------------------.Rock Size...... �� ----------- <br /> Distance to nearest: Well__...-_/�----__----------------------_Foundation-----l4:7 -------- Prop. Line-___.-�_-------�=__-. <br /> REPAIR/ADDITION (Prev, Sanitation Permit#---------------------------------------------------Date -____) <br /> Septic Tank (Specify Requirements)------ ---------- -- - ------------- ---------------------------- -- --- ---------- ------------' <br /> DisposalField (Specify Requirements)--------------------- ------------------------------------------------------------------------------------------------------------- ---------------- <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------- -- -- ----- ---- -- - --Owner <br /> By---------------------------------- ----------- - Title <br /> J <br /> l (if other than owner) <br /> FOR4qPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------- -' 46 -----------------------------------------------------------DATE r-.2- -r- -- <br /> DIVISION OF LAND NUMBER__ -----------------------------------------------------------DATE._-. - --------- ------- <br /> ADDITIONALCOMMENTS------------------------------- --------------------------------------------=----------------------------------------------------------------------------------- <br /> --------------------- ----------------------------------------------------------------------------------------------------f--------------------- --- ----------- -- -- ------------------------------------------ <br /> -------------------------------------------------------------------I-- ------------------------------------------------------------------------------------------------- <br /> = ------------- -------------------------------------------------------------------------- <br /> Final Inspection b <br /> p y------------- Date <br /> EH 13 24 5AN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />