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' FOR OFFICE USE: <br /> FOR OFFICE USE: �s T 4 ,�. <br /> APPLICATION'FOR SANITATION PER <br /> ----------------c.-°'' ----------- --------- Permit No. <br /> (Completfi-in Triplicate) a <br /> ---------- �GIf �G,� o R.K• Datessued__7:. -� <br /> This Permit Expires I Year From Date Issued&,,i,„j,) <br /> .� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br />_.,17his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ; <br /> JOB ADDRESS/LOCATION... ------ -.- --------------- --------- -- - -- - -- - <br /> =.CENSUS TRACT------- ------------ - ----- <br /> Owner's Name ---------- ---:--�'/��-- --��''------------------- ------------ ---------- ---.--.----- ------ <br /> -. "� } Cid <br /> -------------Z1P <br /> Address x <br /> - <br /> Confiractor's -"License 2-. - Phone_44/.f - . _ .� C3 <br /> Installation will serve: % � Residence Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> Motel-El— Other----- ---- -------- --------------------------- <br /> i <br /> Number of living units:. _.-,>' <br /> Number of bedrooms____- -.--Garbage Grinder...:. ---Lot Size-/_�'.��.�_�-���----- <br /> Water Supply: Public System and name...- -----. --------------------'------------- -.Private D., <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ , <br /> Hardpan ❑ IAdobe (� Fill Material-, --------- yes,type__'--------------------__ - . <br /> s I <br />' {Plot plan, showing size of lot, location.of system,in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: Po:septic tank•�or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ` Size___ _ - --------lir_.*_4_4 Ap -------Liquid Depth. S- -------------- <br /> F <br /> Capacity...14_40_4---TYPe ----- ................Material---'----------------- - -N6:-C omp�rtments. ----------- <br /> " Distance to nearest: Well-' - ------- -------Foundation top--- `I---..Prop,rLine----- --- , <br /> t t i Total Lend <br /> '�` ---.----- Length -------= ------------ - <br /> LEACHING LINE- '(?"� No, of'Lines"`_____ ____ _-�_._-, Length of each line__-__-_._.,_...___�_._ <br /> D' Numb <br /> Box.-•--------_Type Filter Material---------------------Depth Filter Material-------------------.------------j------------------------ <br /> nearest: Well i Foundation --- <br /> - Property Line----------- ----------------------- <br /> Distance to <br /> � [ ] Depth---_ 3_i Dl'a-meter <br /> � � G <br /> t er ? Rock Filied Yes NO <br /> .1(3-hr <br /> . # w /I <br /> Water Table Depth---°ii------------=------------ = = - .Rock`Size..+� 1� _ = <br /> Distance'to nearest: Well----------------------------------- -------.Foundation.- ---------- a--.Prop. Line. ------------- -. <br /> I <br /> REPAIR/ADDITION (Prev. Sanitation•Permit'#_------------- -------------------=---- ---------Date----------------------------------------------1 <br /> Septic Tank (Specify ---=------ ------ ------------------------------ --------- <br /> / <br /> Disposal Field (Specify Requirements)._1_4'_��'-V_'V ----------------- ----- ---------------------- -----------= <br /> ---------------------------------------------------..:.. <br /> t -----1- -------------- ------------------------------------------------ --------------------------------- -------------------------------- - ------------------------------------- <br /> (Draw existing and required addition on reverse side) i <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, San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: 1 <br /> "I certify that'i the performance of the work for which this permit is issued,'l shall not employ any person in such manner as <br /> to become ubject to Workma ' o pensation_laws rof..California.' a. = <br /> Signed------ Owner <br /> B - <br /> '- -----------'------ --- ------ ---------------- ------ ----------------------- ,.Title------------------------ <br /> - ---------- <br /> (If other than-owner) + <br /> FOR DEPARTM_ N USE ONLY—'-- <br /> APPLICATION <br /> NLY—'--APPLICATION ACCEPTED BY-- <br /> DIVISION OF LAND NUMBER ------- ----------------- -- ---DATE---------------- ---------------------- -- <br /> -------- - <br /> ADDITIONAL COMMENTS---------- =------------ ------------------ -��------------------ <br /> ------------------ ---------------------- ------------------------------------------------- ---- ------------- <br /> . . <br /> - <br /> ---------------------------------------------- <br /> ------------------------- ----- ---- ---- ------------------ <br /> ------------ -------------------- -. {. ­- <br /> --------------------------- <br /> ---------------------------------- _ <br /> . <br /> - --- ----- - ---- -_ - ---Date ---Final,lnspection by. <br /> f <br /> EH 13 24 �n�l� ;^^� KrnC;AI�HEALTH DISTRICT F&5 21677 REV, 7/76 3M <br /> A I i� _ s <br />