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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT sy _ <br /> �-r <br /> ----------------------- -- ------------- (Complete in T'Triplicate) _./Permit No.. _.�-------- <br /> -- ------------- - <br /> -----------------A �/ 0 Date Issued_ <br /> --------------- - ----- -" --------------- <br /> This Permit Expires 1 Yep%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 Rules and Regulations: <br /> // Tk <br /> JOB ADDRESS/LOCA ION. ��4� x ---- ----- - '------- ------------ --- - CEN <br /> US T.ACT <br /> Owner's Nam ------- <br /> Ci�t - T/L - -.. ---- --- Phone__._- <br /> 1 ; <br /> ----- .------ ,e. <br /> �. <br /> G . �- ' <br /> Address---------- ------------ ------------- --- ------- - i p <br /> .F - . ty � ! Zip ------------ <br /> Address <br /> i <br /> µ r <br /> Name.__ --------:_License #_ -Phone----------- ------------- <br /> Contractor'sInstallaiion-will serve: Residence Apartment House'❑ Commercial ❑ Trailer Court E] <br /> r=-Motel-0:-'-Other- <br />�N mbe'r of livin' units:.._F ______Nurriber,of.bedro msyZ�_-.Garbo a Grinder---------{-=Lot Size-----------------__'_..- -_.-------.-----.-.------.--.-;--- <br /> Water5upply: Public System and name - - ...,° __ - -----------=-.,_.__-----. -------- Priv <br /> ate 2 <br /> Character of soil to a depth of 3 feet: Sand E] 'Silt❑ 'Clay ❑ Peat❑ Sandy Loam ❑ iClay Loam ❑ , 1 <br /> Hardpan [ Adobe ❑ Fill Material._.-________If yes, typ ------------------------ <br /> (Plot <br /> - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc. must be placed on reverse side.) f <br /> NEW INSTALLATION: '(No' septc"tank or seepage pit permitted if public}sewer is available within 200 feet,} <br /> Cil; <br /> PACKAGE TREATMENT [-1 SEPTIC TANK Size-- €_ "-----------------------------------------Liquid Depth--------- --- ----------- <br /> Capacity_ <br /> --- -#---- <br /> Capacity_ Type----------------- i___.Material__ --------- Compartments <br /> tO?- <br /> i <br /> Compartments__:____.'_______ ____________ <br /> ;._ Distance to nearest: Well i-- ----- `----=-_' ...,,. Foundation ==�- = = Prop. Line . <br /> LEACHING LINE of.Lines.; :- :;------ ----=----.::--:,.Length of each line--.-:'�-- -_=_ Total Length ..,.--_------:-----,- _-- <br /> 'D' Box.-:--.._____ :.-- -_--__.__Depth Filter Material_ .--___- <br /> s Type Filter Material �_. ...�. . 4­ <br /> Distance <br /> Distance to Weare <br /> ---- - Foundation,_:_ �"-------- ---� -Pr`.operty Line--------- --------- <br /> De th----_--- Diameter;, -------- s... . .. ... - T .. <br /> st: Wel!_________________ <br />• {SEEPAGE PIT { 1 p Number_`_-_'------------'------------ s"Rock Filled . Yes ❑ No ❑ <br /> Water Tablei`Dep:t ,--�-:; - Rock Size: - ---- - <br /> Distance to nearest-''Well--------------- ---- --- Foundation_..---- .-__4_.Prop. Line------ -------------------- <br /> REPAIR/ADDITION <br /> ---------_ __. <br /> REPAIR/ADDITION (Prey. Sanitation Permit#_.-- ---------------------------:_----------------:Date------------------------------- ----=:------1 ` <br /> Septic Tank'(Specify Requirements)----= - ..._... ------------------ --------------------=--------------------'--------------------------------- <br /> Disposal Field (Specify Requirements)::.-.,, - " - --------------- 4 <br /> P ------------------------------- <br /> --------------------- <br /> - _ X <br /> ` i .. Draw - <br /> ( existing and required addition on reverse side) , l <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 Sari Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the foilowing: ' <br /> "I certify that in the performance b the.work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." � <br /> i <br /> Signed---_-----'--- --�- --------Owner <br /> ._ . . . <br /> BY- - - -- ---- - Title_... .` - 'g t <br /> (If other than own �} <br /> e <br /> FOR-DEPARTMENT USE NLY- <br /> i1 APPLICATION ACCEPTED BY__ DATE <br /> '- ---- - ----- -- --' -------- � DATE'. - <br /> DIVISION OF LAND NUMBER----------------------------------=-------- - -- ilY7 <br /> ADDITIONALCOMMENTS.----: ---- -------------------- -------------------- ------------- -•------------.------------- ------------------------------------=------------- ------------------------ <br /> ------ <br /> ---------------- ---- <br /> 9 - _ ------------------------ -___. <br /> - - _ _ --------------------------------------------------- _____________ _______________ ____-____ _______ <br /> i <br /> -------------------- <br /> -------�,1/.._ - s "` Date_. l <br /> Final-inspection by=-:==--=_- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21877 REV,7/76 3M <br />