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FOR OFFICE USE: .j'"�"`'� FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT qG� <br /> ------------------------------------------------------- <br /> Permit No___ <br /> (Complete in Triplicate) <br /> ----------------------------------------------------- __0 <br /> Date Issued____��.77_ <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/LOCATI N_.. � .- �__ -_ - <br /> ---------------- -- CENSUS TRACT_ 4 Dt <br /> ------- --- Phone--------------------- <br /> Owner's Name.----- c ------ ---------------------------------------- --- <br /> _ <br /> Address...... ,3� _. __ ....6' {---- ------------------- City ? - Zip_q <br /> Contractor's Name_OV9�0_-_i�4 _...... . _ _______________________License #_ -7 --_--Phone_3 <br /> Installation will serve: Residence rtment House ❑ Commercial ❑ Trailer Court ❑ <br /> � Y k <br /> z Motel ❑ Othn r----------------------------- ---------------- <br /> /. a , <br /> Number of living units_________________Number of bedrooms__- _______Garbage Grinder_ -___---Lot Size_____/' Cxte-.---.----._--_- ._.-.n <br /> WaterSupply: Public System and name-------------------------- ---------------------------------------------------------- ---------------------------------------------Privatezl­< <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt 0 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 SEPTIC TANK "�` "size _y +� 9 3 " " � ------ <br /> [ )i [tam /� -�/�-�------------------ <br /> - - --- -------------- Liquid Depth --�- - - <br /> Capacity/� _ •Type f�-��"` '--------MatWial_-�-ll��-_- No.C ompartments-----�------------ <br /> Distance to nearest: Well.���_ ----------------------------Foundation-_lam_ --------------Prop. Line___.7;5- ------------- <br /> LEACHING LINE [A-T- No. of Lines_.------------- Length of each--------Len IineJ_ ..,____.__._ <br /> g Total Length._z0 <br /> �- <br /> __Type Filter Material- L��"�--Depth Filter Ma <br /> D' Box-/./, terial--- - --------- <br /> Distance to nearest:Well.300---------------Foundation _-yp_yr-----------------Property Line__5P__ <br /> ---------------- --- <br /> SEEPAGE PIT [vr De thc�5__.--_Diameter-__ s Number_.-----,Number Rock Filled Yes No <br /> P Y I, r �� <br /> Water Table Depth._Affrf)_`•__f-_{� 'r. _- '1---Rock Size ' <br /> i <br /> Distance to nearest: Well-'/17 ----.____.___.______F oundation___ �_�_._-_._____.Prap. Line_._J��________-__-- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------- -W?:------------ -- _--_.Date----------------------------------------------) <br /> Septic Tank (Specify Requirements) ------ --------------------=-------------- = ----------------------------------- ------------------------------------------------ <br /> Disposal Field (Specify Requirements).................... <br /> -- i� <br /> ----------------------------------------------------------------------------------- ------------'I----------- "" ------------' ---- ------------ <br /> (Draw existing and required addition-on reverse side). -r <br /> I hereby certify that I have prepared this application and that the work wilh be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations`.& 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,-1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation_.laws of California." v ' <br /> Signed- - - ------- --- ---- -------- ------ ---------------------------- Owner <br /> x <br /> �c ------------------------------Title_ Gf/ t ------ -- -------- <br /> (I other than owner) ' . <br /> FOR DEPARTMENT USE ONLY ` <br /> APPLICATION ACCEPTED BY----- _ --------------------- - -.------------------------------------DATE.--,9---1)_ 7- ------ ---- ------- -- <br /> DIVISION OF LAND NUMBER--------------- {"--------------------------------------DATE.---.-------------- <br /> ADDITIONALCOMMENTS------------------- --------------- ---------------------------------------------------------------------- ---------- -------------------------------- <br /> ---------------------- --- -------------------- <br /> Date -Final Final Inspection bY: ��' - ------ -- -�----------------------------------------------------------------------------- - ----�-�---�-�--- --------- <br /> ----- ---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&5 21677 REV. 7/76 3M <br />