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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> (Complete in Triplicate) Permit No. <br /> --------- ------ <br /> ..-- . - This Permit Expires 1 Year From Date Issued Date Issued..:?`. 7_?f <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. 49 and existing Rules and Regulations: <br /> ii ._, . <br /> k JOB ADDRESS/LOCATION_ . d�!_. Q <br /> .... .. ✓d!('� . r. CENSUS TRACT. <br /> -- <br /> Owner's Name....... - _ --�-- ...- <br /> •----------- ....-.-___Phone <br /> Address ASF-. . Cit . <br /> y--•..... ........ ­­--. ..Zi -- .................... <br /> Contractor's Name-. . ... -- - <br /> Zip_ <br /> ... ....... ... . .License #.. Q.. <br /> l ��..- <br /> .. .-------� � ..Phone. --. .�- - - <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> 'Atel ❑ Other-- ....--- -- <br /> Number of living units:----- ---------Number of bedrooms.. _..Garbage Grinder.........---Lot Size...- .-. <br /> Water Supply: Public System and name.....- ......... ..-- - <br /> - --... .... . ........ --------------------------------------• Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ 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,( C"r <br /> ,1 O <br /> PACKAGE TREATMENT <br /> ( SEPTIC TANK [ ) Size ZA..A tCX_1Z�-------------------------------Liquid Depth.----.................S3` <br /> Capacity-.,_14Z,jD----Type.----#— ........ Material- -----------No. Compartments.-----PVI <br /> ----------- ---- <br /> Distance to nearest: We1L:.... � --Foundation.....® ...... Prop. Line..../'~ <br /> LEACHING LINE _....Length of each line,.:.f19(,� .� <br /> ( No. of Lines _. -- ---------Total Length 1.1 ---- -------- <br /> D' Box-..__'....._.Type Filter Material... .. Depths Filter Material....f. --- .--_-.---_--------_ <br /> Distance,to nearest: Well-------- <br /> I <br /> - <br /> ----- -- - - -- ou <br /> ---- ndation....._.---....--...- -.-...Property Line..------------------- <br /> ---.. <br /> SEEPAGE PIT [ ] Depth.__-9, 6 ..Diameter...- -..-_ Number ------------------ Rock Filled Yes No <br /> Water Table Depth---------------------- ------------------------------•--.Rock Size...-f... <br /> Distance to nearest: Well.------ ------ .................Foundation....._.....--- ...........Prop. Line.----.- -;....----....-- <br /> REPAIR/ADDITION [Prev. Sanitation Permit#...................... <br /> - ....... -.-- ---------Date........ <br /> ---•-- ------ -) <br /> Septic Tank (Specify Requirements):.....----- ------------- <br /> - .....-..... --------------- .....-------- <br /> Disposal Field (Specify Requirements)_..,_-...___..:.-....: <br /> ------- -------------------------------- - <br /> --------------------------- - .................. .... .................--. ....... -------• <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 worts for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman'sCompensation laws of California." <br /> Signed - -- ---------...Owner <br /> By...-. .. <br /> ` Title. <br /> { f of er thon owner} <br /> i <br /> EPARTMENT USiE-ONLYAPPLICATION ACCEPTED BY.._-. �� .�FOR <br /> • - - - ......... ----.. ..DATE ,3 �lV-7 <br /> DIVISION OF LAND NUMBER......... :........ --- -- ---....DATE - <br /> - ------- -- ------ • .... . .--- .---------- <br /> ADDITIONAL COMMENTS.............. ....... f - , <br /> ------------ °------------- --- ..................... ------------ ------ <br /> ................------ --- �" c� <br /> - -------------_.....------- ---................ - . .... <br /> ---------- ------------ - <br /> -. --------- - ---- <br /> Final Inspecnon by:............... . x t <br /> ----------------- --Date. !f <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />