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FOR OFFICE USE: FOR OFFICE USE: <br /> ,APPLICATION FOR SANITATION PERMIT <br /> ---------------- <br /> (Complete in Triplicate) Permit No--- ------------------ <br /> -------------------------------------------------------- y/' / <br /> Date Issued.--.�� . <br /> --------------------------------------------------- <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/LO TION..._ __._`4_4 /7 ..__ _ - CENSUS TRACT.___._... <br /> Owner's Name. r -------------------------------------- <br /> Address- <br /> 3 �- 1 - -- -- <br /> Address 0 .. ------- ----- -- - -- .. Cit _-Zip <br /> /_ <br /> Contractor's Name.-_-� -- - _. ---_. __.Phone_.c3_rGLicense # � 7..-a,!_l--- 1F3��_-----. <br /> ______ <br /> Installation will serve: Residence n Apartment 3House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--------------------------------- <br /> ------------ <br /> Number of living units:.---_. Number of bedrooms.2-- -___Garbage Grinder_______4-lot Size----- y ............................________________ <br /> Water Supply: Public System and name------------------------------------------------------------------- i-o_11P°:-----------------------------------------------------Private � <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ /Scindy:Lcam � Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material_---------If yes,'type.... ------------------------ <br /> 4� <br /> (Plot plan, showing size of lot, location of system in relation to wells,-buildi.ngs, etc. must be placed on reverse side.) p� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted'if_oublic,sewer is available within 200 feet,}PACKAGE <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ j Size--,6--.------1.--j 44------------------Liquid Depth__________________________ <br /> Capacity----------- TYPe-----------------�Matarial------------------------- ,o. Compartments-------------------------------° <br /> 1--- <br /> Distance to nearest: Well-------- -------------�__-r--------------Foundation--=--- --------------.--.--Prop. Line---------------------------- <br /> LEACHING LINE [ ] Na, of Lines------ --------------------- <br /> Lengh'� each line--------------------------_,___.Total Length,--------------------------------------- <br /> i <br /> 'D' Box------------Type Filter Material--- _-------------Depth Filter Material:----------------------------------------------------__-------- <br /> - <br /> ._ _ . - - r <br /> Distance to nearest: Well----------------------------Foundation----------------------------Property Line------------------------; <br /> SEEPAGE PIT [ ] Depth___-----_----___Diameter__-! ~' Number--------------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth------- ----------------------------------------Rock Size------- ---------------------------------------- <br /> Di'sta nce, nearest: Weil-------- -------- --------- ------------.Foundation----------1---------------Prop. Line--------------------------- <br /> ---Date <br /> I <br /> REPAIR/ADDITION (Preva Sanitatio Permit#---------------------------------------------- -- k.__ ___.__) <br /> d� I <br /> Septic Tank (Specify Requirements).___ _.....Y______.____._ - ----- --------- --- ------ --- <br /> Disposal Field (Specify Requirements)'(—------ -- - - 1---------. �-� ��r/f /��------------y�/`'-' 2`'LLjf"`f <br /> ------------------------------------- <br /> -------- <br /> /� ---- <br /> --- ---- --------------------------I---- = t . ------------- <br /> '`W - ------- - <br /> - ------�-------------04,--n. _ _ - - --------i------------------------------------------------.---------- <br /> (Draw existing an 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 Hea'Ith District Home owner or licensed agents <br /> signature certifies the following: 1 <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 orkma Compensation laws of California." i' <br /> Signed ------ ------------------ --- --- --- ----- ----Owner <br /> --Title _ ---- <br /> (I other t an owner) <br /> .` FOR DEPARTMENT USE ONLY .�.' <br /> APPLICATION ACCEPTED BY__: .. DATE_7 <br /> DIVISION OF LAND NUMBER. ---------------------------- _r cQATE.' ----- <br /> ADDITIONAL COMMENTS------------------------------ � y — <br /> u --- ------------ <br /> ------------------------------------- ---------------------------------------- -------------- --------------�-----`--------------- --- -- ---------------------- <br /> i <br /> ---------------------------------------------------------------------- <br /> Final Inspection by=----- ------------------------------------------------------------Date 7 �� <br /> EH 13 24 'SAN JOAQUIN LOCAL HEALTH DISTRICT res 21677 Rev. 7176 3M <br /> i <br />