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FOR OFFICE USE: FOR OFFICE USE: <br /> x APPLICATION FOR SANITATION PERMIT <br /> ----------------- ----- Y T . >7_ �3f <br /> ' [Complete'iri;Triplicate)''^ � Permit No.__.______------------- <br /> -------------------------------------------------------- 7] <br /> Date Issued.._____-_-"_._._ <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 Rule nd a lation <br /> JOB ADDRESS/LOC TION. r�_. _ -a5 = - CENSUS TRACT <br /> /� ----- J <br /> Owner's Name----- fyt-� :. `- = - Phone_ /-- �� <br /> _ <br /> Z10 <br /> Address ---=7lPy �G ' [�" Ci# -- zi" 3 <br /> . ,. <br /> Y Pte. �. <br /> Contractor's Name_."._ "' __-____License #---------------""._________Phone' l<__S_-`� �_f-_.._ <br /> = = �7l <br /> Installation will serve: Residence (�i Apartment House.❑ Corrimercial ❑ Trailer Court:❑ ( p <br /> r <br /> Motel ❑ -. .',Other- <br /> Number of living units:_- ------Number of..bedrooms------------Garbage Grinder_______La#rSize_ a_r y.''o" _-_.t_.._ t <br /> Water Supply: Public System:and_narrie :' -----i . . .__. -------------------------- -- -------- Private <br /> Character of soil to a depth of 3 feet: Sand Silt 'Clay Peat Sand Loam Clay Loam 1 <br /> P ❑ .. ❑ Y ❑ � ❑ Y ❑ Y ❑ <br /> r Hardpan ❑ Adobe 5C 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: " 1(No`septic tbnk or seepage pit permitted if public sewer is avoilabld Wi hin 240,feet,) `l i <br /> PACKAGE TREATMENTSize1 _ I i 4 <br /> [ ] ------------------- ------------=--------- ---Liquid Depth.'---;----` - <br /> [ �] "'• SEPFIC TANKi <br /> { Capacity- ' --------------Type- -------Material--------------------------No•:'Compartments--------- _-k-------- q <br /> .. : . . . . .Distance'.to nearest: Wel! ..... --_--.-".>- <br /> ---- :Foundation -- ".Prop. Line--- <br /> LEACHING LINE. [ ] . No..of.Lines_.------------ ,__ _,Length of each line Total Length --- ", <br /> .'D' Box--,---.- _Type Filter Material__ __ .__.DeptH Filter Material--------------------------- _t_ <br /> 1 ' <br /> F <br /> Distance to nearest: __._.,_�. Foundation-_-___------------- .Property Line________:____. <br /> �.. . ............... -..L... -{-:_. <br /> : <br /> SEEPAGE PIT { ] Depth-_--1------°__._Diameter-..__-________s._._Number_________________ _"__-___._____ Rock Filled Yes❑ No ❑ <br /> i..j_ P .,.... ; <br /> Water Table Depth.---.------------... -- -------------- ----------------.Rock Size---- ------------------------------------------- <br /> Distarice <br /> -------------=-------------------------- <br /> Distance to nearest Well--------------- --------------------------Foundation------ ".""_"""____:Prop, Line----- _____4___--___.�_:__.. <br /> REPAIR/ADDITION ]Prev.Sanitation'Permit#-------------�-----�-= -�--�---1:----'--l:'-------._.._-:Date-------------.--_------------------------------- <br /> Septic <br /> - -------------------- _-_-_Septic Tank (Specify Requirements) = _ r s = Y} ]: -• ! <br /> ------------- <br /> -------------------- <br /> Disposal <br /> -- <br /> 't <br /> 5Disposal Fjpld pecify Requirements)_ -------- ----- - ------- -- ----- ----------- - -----r ------- <br /> i '-- <br /> ------------------------------- - <br /> ---------- (Draw- <br /> existing and required addition on reverse' 'si <br /> del <br /> Thereby 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 /> signatu're,certifies the following: i <br /> "1 certify t atjn the performance of the work for which this perriiit is issued, I shall not employ any person in such manner as <br /> to becom s bi- t to <br /> Wor _aensation laws of California." <br /> ............... <br /> - .. ------.Signed -------- --Own <br /> er <br /> ----- ----------- Title--- <br /> -. <br /> ------------- <br /> ` <br /> (If w- --------- <br /> BY of than ner} <br /> [ `+ 1 FOR DEPARTMENT USE PNLYj - <br /> APPLICATION ACCEPTED, BY------------- ---- ---- ---------- -- ------ --- -- - - --- ---DATE --- - - --------- <br /> --------------- <br /> DIVISION <br /> ------- =DIVISION OF LAND NUMBER,_ --- - -------- ---- ------------ ------- ----- ------------- ------ - ----I--n------------ DATE. <br /> COMMENTS /. `� --------------------------------------- <br /> ADDITIONAL � <br /> --------- --------- ----------------------------------------------------=-- ---------------------- -- -------------------------------------------------- ---- <br /> --------------------------- ---------------------------- ----------------------------- -------------- - <br /> --------------------------------------- <br /> ------------ ----------------------------------------------------------------- - ------- - <br /> Final Inspection-by:------- = ---- --__-_. --==--=--=--- <br /> �� <br /> Date...----- <br /> FH 13 24 k <br /> F&S 21677 RE)f �6 3M <br /> 'SAN JOAQUIN LOCAL HEALTH DISTRICT. � __ �� <br />