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FOR OFFICE USE. I j Ch/ o n <br /> APPLICATI N AOR SANITATION PERMIT <br /> .� .._.�i..6...................••- 3-970 <br /> ......... .................................... <br /> (Complete in Triplicate) <br /> .......... Permit No. .. ................ <br /> This Permit Expires 1 Year From Date Issued Date Issued': <br /> Application is hereby made to the ScinXoaquin Local Health District for a per to construct and install the work herein <br /> described. This app[ica#i Is U2acle)6 compliance NCun, <br /> y Ordinance No. 519 and existing Rules and Regulations: f <br /> JOS ADDRESS/LO T ,�.. CENSUS TRACT ..........:.........._... <br /> Owner's Name-.........F .... _. -_ ._ . ''OM1M1.-. �j. .. ..... '...... :.Phone ...........................:....:... <br /> Address ................. SdJ..i. i.. •;!1t_ - t._. City ... ?Ca=::..... <br /> Contractor's Name .�� ..... .. :. ---__.Li+cense # �J.,r � . Phone �� ,.�..: <br /> Installation will serve: ' Residence partment House❑ Cot merclol ❑Trailer Court <br /> Motel ❑Other ..................... <br /> Number of living units:_.......... Number o Brooms arbage Grinder -,VU--- Lot Size .I- .`" /. --------------- <br /> Water Supply: Public System_and name .....................................................Private ❑ <br /> r _ _ ....-- ---•--. <br /> Character of soil to a depth of 3 feet: Sand❑�ilt❑ socia I Pett❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material, If yes,type __---_.__________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I <br /> f <br /> NEW INSTALLATION:* (No septic tank or seepage pit permitted if p ,blit.sewer ' vailable within 200 feet) �� <br /> PACKAGE TREATMENT [ SEATIC TANK Si ... . ... .............. Liquid Depth - .___..__.._..._._ <br /> Capacity .� Type _ _---- Material--- o. Compartments ._ ...... <br /> Di ce to nearest: Well � _ I _Foundation Prop. Lined <br /> F � <br /> [ --. ... :a......... .. <br /> LEACHING LINE No, of Lines ..- _- Length of each' line.--- �._..._... Total Len th` ......................... <br /> [' Box . __ Type Filter Material _lO._ �_bepth Filter MateHal ....../- ...........................� <br /> Distance"to`ned i st:TWell ": _-.... Foundation Q.�._-_. ._.. Pro a Line J <br /> �tl 1. _ p �r <br /> SEEPAGE PIT Depth � .... Diamet/er .•.. �- .- Number ......... ..r... Rock Filled Yes No Q <br /> Water Table Depth ---------- .....Rock Size ---- <br /> Distance to nearest: Weil ._...�4) A...................Foundation ........ Prop. Line -_•__•- ....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .........:.t......r............................ Date --------•--------------•-----•--- <br /> • i <br /> Septic Tank (Specify Requirements) ...........•......--•................... --------------------------------------------------- .............. 7........ -------- <br /> Disposal Field (Specify Requirements) ....................�_ - <br /> ...................... <br /> ... . -------------------------------------------------------------------- <br /> ............ <br /> ....4.. <br /> E <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 <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following.— <br /> "I <br /> ollowing:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ....................... Owner <br /> By .................... ��... ::...... Title ........_...-.. Z.... :. <br /> (If in r t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... ... . ............ ........... ................. DATE ... <br /> �©r�.. ....... ......... DATE <br /> ADDITIONAL COMMENTS <br /> ......••--•............ - <br /> = ........................ .........•---------•-•-- •---•....._........-----............. <br /> .. <br /> ---- ...._.... s <br /> ........... ................. <br /> ....... .../--• --- ^ --.I....... <br /> Final Inspection by :. J' ' <br /> --- Date -------- :.?.�..: ..---•---- <br /> ' � „JLOCAL HEALTH DISTRICT <br /> F w 13 24122 DAU Kiu� 7/79 3 u <br />