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i <br /> i <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------- �-'- <br /> 4, (Complete in Triplicate] Permit No----------------------- <br /> ------------- -------------- ----- -- + x `/br <br /> e " . Date Issued.-.'-- <br /> Application <br /> ssued.-. -- 7� <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued '� <br /> ----------- <br /> 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 Ordnance No. 549 and existing Rules and Regulations: <br /> ` , ._____,___.. -------------------------------------F---------------JOB ADDRESS/LOCATIO -CENSUS TRACT-------------------------- -- <br /> -- <br /> Owner's <br /> Name f - Phone- <br /> - ----------------- <br /> ---- <br /> 3 <br /> Address -------- - City- g = zip <br /> Contractor's Name.- - - -�-- _ ----- ------------- - --License # 7l 3F Phone_.i� -5G',1°- <br /> a _ <br /> Installation will serve: r Residence g `Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> + a i.... Motel ❑ Other--------------- <br /> ' --------------.----------------- <br /> Number <br /> -- ------- -- --Number of living units:---_ -.- Number of bedrooms___ _-____Garbage Gri der_.._._...__Lot Size --- -— S.�__.-_____________: <br /> /; X f <br /> Water Supply: PublicSystem and name----------- :__: ---------------- ------ ,._--` -----------_.----------------------------------------------------Private k <br /> Character of soil to a depth of 3 feet: ' Sdnd ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ I ~� <br /> Hard par'❑'e Adobe Fill Material'..-- ------1f Yes, type---.------•--------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, bbildings letc. must be placed on reverse side.) <br /> NEW INSTALLATI614:6 .(No septic tank or seepage pit permitted'if public sewer is available'within 200 feet,) <br /> PACKAGE TREATMENT+ [ ]" SEPTIC TANK ` <br /> [ ] Size = Liquid Depth : -f--------------- <br /> I <br /> L,Capacity---- --- ----------- Type ----- ---------- --Material---=------ -----------------No. Compartments--- ------------------- ----W' <br /> t " Distance to nearest: Well-------------------- -----------------------Foundation------------,_____-------.Prop..Line-.------------------------_. <br /> r � - s <br /> LEACHING LINE: [ ] No. of Lines-.------ Length of each line.--.-------'-----_i4__.------Total Length --.---------------------------------'-- <br /> _ D' Box_ Type Filter Material—.= �--.-------- ------Depth iter <br /> Material... -. -------------------------------------------------- <br /> Distance <br /> ----------- ------------------=--------Distanceto n-earest: Well_'----------- - _------ Foundation---.-_----. .----'.Property Line-=---------------------------- <br /> µ- - t <br /> SEEPAGE PIT Depth----------- ----Diamete -_-.--_Number.- --------------------------- ---- <br /> Rock Filled Yes ❑ No <br /> Water Table:DepthRock Size- ------ <br /> ------ -------------- <br /> ----------------------------------------- _ i <br /> i Distance-to nearest:.Well_..____:"________________________________-Foundation--.-.--- Prop, Line.----.---.- ,_----- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------=Date--------------------------------------------.), <br /> Septic Tank (Specify Requirements)._"-------------------------- <br /> e = Pr <br /> Disposal Field (Specify Requirements].. x -�-------�------- �--'�--' -----,;Z ------ --- <br /> - -- ---• , <br /> ---- -- --- ------------------------------ ------------------------------------------------ ------ -- ----- <br /> (Draw existing and required addition on reverse side] } <br /> I hereby certify that.l.,have prepared this application and that tate 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 work for which this permit is issued, I-'shall not employ any person in-such manner as h <br /> to becom s ct o Wog a Co pensation .laws of California." <br /> t ; <br /> Signed = - = -- ---- ----Owner <br /> F BY .- - / ------------------ Title - ----—:----- -- <br /> 4 (If"other`than owner <br /> �, /FOr#DEPARTMENT USE ONLY -� <br /> APPLICATION ACCEPTED BY---- - 2 --------------DATE---_-' -- v---------- � <br /> DIVISION OF LAND NUMBER:--_-- _DA E____ _______________ _ <br /> - ------------ --- <br /> ADDITIONAL COMMENTS-------- - - _.--_ '1-- - 3 <br /> ------ <br /> Ii ------------------------------------- -------- --- ------------------------------ ------------------------ ----------------- ---- ------ ------------------------------------------------------------ <br /> -----'----------------------------- -- ----- ------- -------------------------------------------------------------------------------- - --- ------------ <br /> - <br /> -�� <br /> Final Inspection b ----- -.Date-,. = <br /> P Y � ----------- ------------------- ------- <br /> eH 13 sa ..� AN JOAQUIN LOCAL HEALTH DISTRICT gas scan eev, ���6 3m <br />