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FOR OFFICE USE: jt� FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .................................. . ta.=.. . <br /> �- ��-��---� (Complete in Triplicate) Permit No.. . <br /> ....................I.................................... <br /> Date Issued.-M-:3.-'J <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 'Jper. 54499/apd existing Rules and Regulations: <br /> JOB ADDRESS/LOCA Nom.- ! - - �L-`% QD��'� ��`�� .........CENSUS TRACT....._....... -- .......... <br /> Owner's Name_.. .. U�EG_.._.. _._._.... ........................ ......... .Phone._.........-------------------.. ... <br /> Address_.._.. .-. .... ,�f ......... ....... City__.......r..................... <br /> [. -¢lty ._........._.Zip ...-..0 r ..... <br /> Contractor's Name. /�¢- �� G. -----........_License #✓--�.y----11. ..._Phone. ....,jl.. .~/ ..... <br /> L- -! .. <br /> installation will serve: eR sidence I Apartment House ❑ Commercial E] Trailer Court ❑ <br /> / M tel F-1 Other...... ..... ...-_--------------------- s1 <br /> Number of living units;.......f-.......Number of bedrooms...._. Garbage Grinder....._.....Lot Size.--... ."�-......---"....- <br /> rVater Supply: Public System and name.. . .............. ----- ---.---------.Private <br /> -haracter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Laam4 <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 an reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) - <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ( ] Size .*X 4A10 ----"-Liquid Depth......--- ----- ---- <br /> Capacity_/A�0,Q------ Type-.,4-------- ----- Material_4f--W..........No. Compartments-----a..-................._- <br /> Distance to nearest: Well-----/.4J...Q. .. _. .... .........Foundation..... Prop. Line.............. ...-........ <br /> -EACHING LINE [ 1 No. of Lines -�' ................._Length of each line-.....4f.-p........-. ---Total L�� .�ptLQ - <br /> ih � "- . --"-..----------- <br /> 'D' Box-./. Type Filter Material._._ ... Depth Filter Material.._,.I'. ...__.---_............. ......_..._. ------- <br /> Distance to nearest: Well..-. -/�.,1/._._..... Foundation............................Property Line.............. <br /> SEEPAGE PIT [ ] Depth..A.A._.Diameter.... -. Number3..-.--......_............ Rock Filled Yesf No❑ <br /> Water Table Depth--------------- --- ..Rock Size_ - � ----------_------ -- <br /> Distance to nearest: Well...-.--....................................Foundation................ .. ."....Prop. Line........................... <br /> iEPA1R/ADDITION (Prev. Sanitation Permit#---------------------- ---------_ ----...........Date.................-....._........""_-.........I <br /> -optic Tank (Specify Requirements). . .. ................--------------- - -- ---- <br /> 'isposal Field (Specify Requirements).....----------------- .. .............................-.................................... .. ...........---..................._.............. <br /> .--------------....................................... ............................ ­.......................................... ....... .......................................... <br /> ................-....................................... .............1 - ......... .......... ...........................................................- ... ---------------- <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 /> "1 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 /> _ -..-- -...... __. .. Owner <br /> Sig ned.-.". i ._. <br /> — Title.-- __.... - - .".... .-... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------- 1... ._.. ...--------- ----- ---... <br /> . .DATE <br /> DIVISION OF LAND NUMBER.----------- _ -- -------- _ ---.----- - DATE.................. ...... ..... ._._.......... <br /> ADDITIONAL COMMENTS.._.._............ . <br /> . ......................... ..... .. ... ...... ....... .. ............................................................----............._- ------------- <br /> - ........_...._.... ..........._.__.._... _ <br /> ... .. .........................--------------------.....-..----------:...... ................ ------. .. <br /> _. _... 7� <br /> } <br /> te <br /> Final Inspection b -.....-- -- - -- -------..Da <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FLS 716]) REV. 7/76 7ti <br />