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FOR OFFICE USE: 3 FOR OFFICE USE: <br /> APPLICATION FO'R SANITATION PERMIT <br /> ----------------------------------------------- 7 <br /> (Complete in Triplicate) a *Permit <br /> -------------------------------------- ---------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued__— __,?9 <br /> r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrbct.and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ; <br /> JOB ADDRESS/LOCATIO C <br /> � � � C <br /> Owner's Name. ----------- 6 ] h <br /> y= <br /> T. <br /> Address__-_. <br /> �. .. -- " -------------- ------City - 'L------------Zip- --- <br /> Contractor's Name . -----: : ' <br /> �" - --- ---------------------License #_��f��---- --Phone_ <br /> Installation will:serve: Residence ❑ ❑, Trailer Court ❑ <br /> ��Apartment House. Commercial <br /> r i Motel ❑ Other ------ L <br /> ,.. <br /> Number of living.unit"s:___ /. --__Number of..bedrooms:_ ' _Garbage Grinder._ Lot Size__ <br /> Water Supply::PublicSystem••and name •` ' -__. : <br /> Character of soil to ddepfh of 3 feet: Sand ❑ S It❑ clay <br /> Peat Sand Loam Private <br /> t r"° i ;._ ❑ y h ❑ +.Clay Loam 0 <br /> * ,.Hardpan ❑ i AdobeFil! Material es, 5 <br /> Y type y 4 <br /> (Plot plan, showing size of lot, location of system in relation towellsbuildings,•etc. must be placed on reverse side.) <br /> NEW INSTALLATION:' (No septic tank`or seepage pit permitted if public sewer is available within 200 feet,) # <br /> PACKAGE TREATMENT [ ] SEPTIC TANK <br /> [ j size_ : ------- -----Liquid Depth..--------------------- <br /> CapacitType_ = ' ------Material-----=--- --- --------- Compartments <br /> __-_:: -- ---,---- <br /> ° Distanceto nearest: Well------ <br /> yf <br /> ------ --- ------- <br /> ---=----Foundation = - _, = Prop.-Line_-------------- <br /> LEACHING LINE I ] . No.�of Lines__ _ ____ ___(_,_.Length of each line------- Total Len <br /> YP ;� ; p . Length__ ------------------------ <br /> D' Box--°----_ 1.---,---Type Filter Material--------------------De Depth Filter Material-----_------------ <br /> j4 --------------------- ---------� <br /> Distance to nearest: Well-------------- .-----_-- --Foundation--------------_------- - _--.Property Line. --------- <br /> SEEPAGE PIT [ ] Depth------------------Diameter-____------ Rock Filled 'Yes ❑ No" <br /> - :------'-- <br /> 1Nater Table Depth - Rock Size----------- <br /> ------- - <br /> REPistance.to nearest:WeIL:--- -- - Foundation--------- Prop, Line } <br /> --- <br /> AIR/ADDITION (Prev-.,(PreySanitation Permit#_______ ________ ---------Date___------------------ <br /> -----) <br /> Septic Tank (Specify Requirements)._--_______ <br /> Disposal Field(Specify Require ents}.- � <br /> --- -------- <br /> --------------------------- --- -_------ <br /> _ ------------------------------ <br /> " (Draw existing and required addition on reverse side) I <br /> I hereby certify that,I have-prepared this application and that the work will be done in accordance with Son Joaquin'County r <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 perinif'lsissued, I shall not employ any person in such manner as <br /> to beco bject to Workman s Compensation laws of California." <br /> ,� .,,�� <br /> Signed---- �_ . <br /> .- .. ------------t :---::.------ ..�---�Owner. " <br /> BY- ---=---------------------------- ----=----- ------ <br /> ----- itle-- = --- --------------- ------------- <br /> ' (If other than owner) <br /> s <br /> FOR DEPA TMENT USE ONLY ' t - t <br /> APPLICATION ACCEPTED act► t�- 1. _--�:_ <br /> • ------------------------ DATE.= �_ _ _' --- -- ----- ' <br /> DIVISION OF LAND NUMBER.---------------------------. ---------------- <br /> . - . :,r-.---- -- ----.----------- -------------- ------- --DATE --------:----- ----- f <br /> ------------------ <br /> ADDITIONAL COMMENTS-_.________________________ <br /> --- <br /> a---------------- =-----=----------------- ---------------=------------------ ------ - --- I <br /> = "" '----------- --------------------------------- <br /> Final <br /> - <br /> - ----------- ------- - 111--------------- ----- <br /> Final inspection by: � - -�---. ---`Date.: _ `_ <br /> a _ "� <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 RFV. 7/76 3M <br />