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FOR',OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------- -------------------------------- Permit No. <br /> (Complete in Triplicate) - - ' <br /> ------------------------------------------------------ Date Issued_ 7%�-'�q <br /> ­-------------------- ---- This Permit Expires 1 Year From Date Issued <br /> r <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: i <br /> a. a • _ <br /> �� .CENSUS-TRACT_............... <br /> JOB ADDRESS/LOCATION.... v� 'i _ ------------------- -------------------------------------------------------- <br /> Owner's Name-`--<. --------a - ------ -----?------------ ..---- -----------=--------------------------- r----: hone_ -- =_- ---7'�----- <br /> {{��11__3o Ci ------------ <br /> Address-------------rr - -------- ------ ------ tY---- p <br /> -------------------------- <br /> Contractor's Name - ' - - License #. �7. .---.Phone- �"r '- .. <br /> - s - - <br /> Installation will serve: Residence P" Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------- ----------------- <br /> Number of living units:--/----:------Number of bedrooms.. ;._._._Garbage Grinder... ..,.-Lot Size-------14) e—-+-_______----------------------- <br /> Water Supply: Public System and name---------------------------------- --------------------------- ------------------------------- ---------------.----.-- ------Private.E, <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam jj�4- <br /> Hardpan ❑ F Adobe❑ - Fill Material...---------If yes, type___'----------------------------- <br /> (Plot <br /> -------- -.(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be.placed on reverse side.) j <br /> NEW INSTALLATION: (No:septic.tank'or seepage pit permitted if public sewer is available within 200 feet) <br /> PACKAGE TREATMENT [ ]" SEPTIC TANK [�-Y Size___- <br /> -x�,�/--------' - ----- Liquid Depth `Vr _•� <br /> / <br /> Capacity---16-- -----Type - ------Material- -4D4 _ ";�No. Compartments.--?--0o----�------- -------------N <br /> Distance to nearest: Well.'--- -------------------- ------=--------------------Foundation----` 0---------------Prop. Line-,70------------------ <br /> or <br /> LEACHING LINE [ .] No. of Lines----- ------ -------- <br /> --..Length of each line------___,__------------ .....Total Length ------ ---------------------- <br /> - <br /> Y �e <br /> D' Box-_�--.....Type Filter Material-... --------Depth Filter Material------_--:-A-------------------------------------------------- <br /> 1 S Foundation-----a$--------------:P o ert Line---- ---------------- <br /> p Distanceta nearest- Well __Foundation rIA <br /> P Y <br /> SEEPAGE PIT [ ] Depth -.-_.._.Diamete - Number...:--.__ ------_----------- %�I Rock Filled Yeses, No}❑ <br /> Water Table Depth.-- [ -------- -------------------------------- ---.Rock Size ,' �` ( ----------------------- <br /> I ! <br /> Distance to nearest: Well..:.... _--�d.+-------- r) s t P 75 <br /> -Foundation rt Pro Line <br /> (Prev. Sanitation Permit#--------R- ------------- -.Date-,�._� ----- .-------=------------ <br /> REPAIR/ADDITION <br /> l <br /> Septic Tank (Specify Requirements)--------- - -- ----- <br /> �----=-------- r -------- ---------=----- - -----, <br /> I` ., <br /> Disposal Field (Specify Requirements)- . ----- --------------- - ."i f ---'---------------- ----- <br /> ---------------- ------ --- ---------------------- ---------------- <br /> - =�, -- �-- <br /> --- --------------------- ' ,.- <br /> ------- <br /> i (Draw existing and required additionson reverse sia 4]1 <br /> I hereby certify that I have prepared this"application and-thatvthe-workill-.beldone n' accordance with San Joaquin County <br /> Ordinances, State Laws.- and Rules-and Regulations of.. the San Joaquin Lacal Health District. Home owner or licensed agents <br /> signature certifies the following: C. �;� <br /> "I cern that-in the erformarice'of the work for,which this-permW(�'issuea, I skall not employ any person in such manner as <br /> certify p � .s.� � r <br /> to become subject to rkman's Co pensation '�awsc of Califorrf� ; <br /> ----------------1 <br /> Owner <br /> BY ------------ --- --r;Title a Ne---' - <br /> (If"other than owner) Wig, It <br /> 'FOR DEPARTMENT USP ONLY 1 <br /> APPLICATION ACCEPTED BY - -------------------- DATE. r ..--- <br /> DIVISION OF LAND NUMBER. ---------------- - DATE - F <br /> ------ ---- <br /> fADDITIONAL COMMENTS---------------------- -------"------ ---- --------------------------------------------------- ------------------------------------ --------------------------- <br /> - ----------------------------------------------------- - ------------- --- ------ ------ ----------- <br /> ---- -------------------- <br /> ------------------------------------ ----------- ------ - -------- --------------------------- <br /> ------------------------------------------------------- <br /> Date.-. it <br /> Final Inspection by _ --------------------------------------------------- - <br />� �--'- � --- - � - -,�- - -- F&5 21677 REV. 7/7E <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />