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FOR,OFFICE USE: FOR OFFICE USE:. i <br /> 3� APPLICATION FOR SANITATION PERMIT J " <br /> (Complete in Triplicate) <br /> Permit No..-. SS <br /> -------------- Date Issued <br /> --4. 711 <br /> - d <br /> .................... ............-....... This Permit Expires 1 Year From Date Issued <br /> ........ <br /> Application is hereby made to.the San Joaquin Local Health Dis-trict.for a permit to construct and ins work herein described. <br /> This application is made in compliance with County Ordinance No. 5Q9.and"ezistik' ,Rules and Regulations:„ <br /> JOB ADDRESS/LOCAT! N --�.f-�- .CENSUS TRACT------------------ ........... <br /> Owner's Name.._. .. • . --Phone ................ <br /> Address ........,.-.-City........ :. ......::..:...:....:. .:..:.....Zip---=-- --- ----_------ <br /> Contractor's Name. ...License #;.17.7/7Z....Phone. J� <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ 3 <br /> Motel ❑ Other-- ------ ----- -------- ` yt, <br /> Number of living units: of of bedrooms-_.. ...Garbaqe Grinder--------....Lot Size----- �./`.:�: . .. --------------- ........... <br /> Water Supply: Public System and name------- --------- �-����----------.---------- .Private El <br /> Character of soil to a depth of 3 feet: , Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material _ _... ....If yes, type----------------- -------- ---- <br /> (Plot plan, showing size of lot, locatioe <br /> n of system in relation .to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is pivailable within 200 feet,] <br /> PACKAGE TREATMENT SEPTIC ITANK Size..' '--- .- - ---Liquid Depth------ <br /> Capacity- �'',V.&V-TYPe-­-4..... - ..Material.- --1-...No. ,Compartments... °ver ------- <br /> Foundation.-..-�.. <br /> --,. Line-----�,-- ...---- <br /> _. Distance to nearest: Well-'..-': .:_ - -- ��j <br /> P• <br /> Pro <br /> A <br /> LEACHING LINE [ ] No. of Lines' <br /> -.----................... Length of each line Total Length <br /> 'D' Box--...........Type Filter Material._-/.I. .....Depth Filter Material--.--/-- -- ---------------------------- --------- <br /> Distan o e rpWell------�. undation-..._/-- `............Property Line...". -.,--------- --- -- - <br /> SEEPAG --- iometer--------------------Number--.-/------------------------------- Rock Filled Yes No <br /> Water Table Depth..................--------- -- ------ --- --- - -- Rock Size..---�.:.1 -------- :.-----...... <br /> Distance to nearest'We11----------------------------------- -------Foundation_.........-- .._.°_ _.....Prop. Line.... _...--.------ ------ <br /> /ADDITION (Prev. Sanitation Permit#.. ....... ...............Date--------- ............... ------- -] <br /> REPAIR/ADDITION � ` .� <br /> Septic Tank (Specify Requirements)---_`.....................-...................... -- -------7-...------------------- <br /> . .......... ....... ......------........I --------- <br /> Disposal Field )Specify Requirements)......... ---- . - --------------- - -------------------- -----.----........... <br /> ------------- ----- - ----------- <br /> ......- <br /> i <br /> .... ..-= ---- ------------- <br /> ------.... <br /> {Draw existing and 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 /> i signature certifies the following: <br /> 46 <br /> 1 certify that in the performance of the work for which this permit'is issued, 1shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed "----------- ----- ----- :..Owner <br /> Title.............. <br /> By---- -... <br /> A�p <br /> - <br /> I (If other than owner) <br /> I �9 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------- --- .--- --.............................. -DATE . .SR. . . ....... <br /> DIVI <br /> ON <br /> F LAND <br /> ADDITIONAL ONOAL OMM NITS.ER-. ......._.i,.......-------i- ---•- ------------------- - - -- - ----------------------------- ........._....DATE..... ... ..__ ..._ ...... ,. <br /> ------ -- ----------------- <br /> .................... .......Q..J� ----- -------------------------------------- -------- ---------------------------- ---------------- -------- -------------- <br /> --- ./_ <br /> . <br /> --•-------------------------- <br /> Final Inspecttan b = ..........Date.. ' . ./ - <br /> EK 13 24 SAN JOAOUIN LOCAL HEALTH DISTRICT Fg5 21677 R76 3M <br />