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FOR OFFICE'-USE:- FOR OFFICE USE: <br /> ' APPLICATION FOR SANITATION PERMIT <br /> ------ Permit <br /> (Complete in Triplicate) <br /> •.........•---- ------ --- <br /> ' - Date lssued/c�X.=S_lu <br /> 3 <br /> ........................ —-------------.._.-.--...-..- This Permit Expires"I Year From Date Issued <br /> I <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 Co-unty Ordinance No. 549 and.existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION. ---------- ff C NSUS TRACT <br /> '�' YG Tis- ei✓-. trey--.- ......Phone. <br /> - ---r <br /> Owner's ,Name.........�� <br /> i' ' . <br /> Address--------- ........... ----------------- --- ---- City----•------------------------ ---•------�-------zip------- -----------.----- <br /> Contractor's Name._ Z <br /> C'-' -... 0. '� ....-License # / ...Phone / Q -------- <br /> Contractor's <br /> will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court 0— . <br /> Motel ❑ Other--..--- ------------ --- • <br /> ..:........ .............Number of living units:- ----.---- Number of bedrooms..-.- --_...Garbage Grinder- _- Lot Size---- <br /> I . <br /> • <br /> Water Supply: Public System and name--- -- ----------- ........... ---- - --- "---- - - --------privateEr <br /> Character of soil to a depth of 3 feet: Sand ❑ ,Silt ❑ Clay [Peat ❑ Sandy Loam ❑ Clay loam ❑ <br /> �. <br /> Hardpan Adobe Fill Material -.If s,t <br /> ye type • ------------------ <br /> �_ f <br /> i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> ZZZ <br /> E NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} �t <br /> k Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth-.-.--------------- <br /> Capacity..... <br /> -_------------Capacity--... ---- Type---........ ...........Material----- ------------- ,:.:No. Compartments--..-.:.:. --;-_----- <br /> Distance to nearest: Well----------- --- --- -- ---- ---------Foundation..----- .... -- ........Prop. Line..------- ...-..... <br /> LEACHING LINE ( ] No. of Lines..............---------------Length of each lins-------------------- -- --- Total Length -. .-----------------...... <br /> .----------- <br /> 'D' Box----.:... _Type Filter Material-------- ----- - -- Depth Filter Material........---.----------------------------- ------ <br /> ----------.....--. <br /> r <br /> Distance to nearest: Well----------------------------Foundation------------.------------...Property Line.............-- <br /> ` � <br /> SEEPAGE PIT [!�]� Depth.. '�!?-. ...-Diameter-...3 --_-- -.Number _-.__27 ----------_------ Rock Filled Yes K?-'No <br /> N [� <br /> Water Table Depth.----------------9� -...----.Rock Size. �� : <br /> 1. <br /> ----Foundation.-_46.-.. .- .Prop. Line.----/-0--- <br /> -_--_--,-(��--.-.------ - �-�-� � --- - " <br /> Distance to nearest: Well._ �------ <br /> REPAIR/ADDITION (Prev, Sanitation 'Permit#------.........-------------------------- --------- <br /> Date----•------•-----------------...-- --------- ] <br /> Septic Tank (Specify Requirements♦..._ - ------- -. <br /> [� ...- <br /> Disposal Field (Specify Requirements]....---...I4�..---- t - it L �. ��/-` ---- Z. <br /> l I <br /> ------------------ =s---- ----- ---------- ------- -- ------.....: - .... <br /> -------- <br /> --------------------- - --- --------------------- <br /> �°' `(DrpwTL!e Nting acid 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 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, l shall not employ any person in such manner as <br /> to become subject to Workman's' Co pensation laws of California." <br /> Signed------ QST-.� ! --....-- Owner <br /> By.........:. -U h -..-.. Title..- " ---------------- ------------"- - �U <br /> (If other than owner) <br /> FO DEPARTMI= T USE ONLY <br /> APPLICATION ACCEPTED BY-------- o�- <br /> DIVISION OF LAND NUMBER.--------.-- DATE_... <br /> ADDITIONAL COMMENTS------ --- ------------- _.... <br /> k ----------- ----------------- ------ --------------...- <br /> ----- -------- ---------------- <br /> -- -- ---•-_ ------------------ --- : : :: <br /> ------------------ ------------------------` ------- ----- Date... <br /> Final InsRecnon by:_..------- -�.*-..---- - - <br /> EH 13 2a SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REv, 7I76 3N <br />