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FOR OFFICE USE: FOR OFFICE USI:: <br /> Z.! 3o APPLICATION FOR SANITATION PERMIT 11 <br /> .......... .. ... .......... 1�_ 3 <br /> (Complete in Triplicate) Permit o..99 --- ------- <br /> .......................................... .........­ 11 <br /> : Date lssue4l.- A�__::191 <br /> . <br /> ..................•....-.............. ------- _This�Permit Expires I Year From Date Issued <br /> Al <br /> Application is hereby made to.the Son Joaquin Local Health District for 0,permit to construct and install the work herein described. <br /> This application is made in, compliance with Count Ord* ante No 49 and existing Rules and Regulations- <br /> JOB ADDRESS/LOCATIJQN/-------- -- ------ - <br /> T----------------- <br /> TRAC <br /> Owner's Name.... . .... !I <br /> . .... -- ----------- --------------------------------------------------------------------Phone......------ 1__.___,.___-_...... <br /> it <br /> Address-- ................. Z. <br /> city........... ........I------------------ tp-------------- <br /> Contractor's Name........- . .... ..........License # Phan <br /> ................0----------- ----- ---------- - <br /> Installation will serve: ResidenceX A�rpartmen;t H use­'E� ] Commercial E] Trailer Court 0 <br /> Motel F-1 Other--------------- _------ ........... <br /> Number of living units:-...... .:`....Number of bedrooms..;. ._.Garbage Grin _er-------.-Lot Size---.. -'.Q_.. ... `�..:._..-- -- ----------------_................. <br /> Water Supply: Public System and name.. ............ _-Private ❑ <br /> Character of soil to a depth of 3 feet: Sand-ED Silt Itl Clay El Peat E] Sandy Loam F7l Clay Loam E] <br /> Hardpan E] Adobe E] Fill Material.. ---- --- If yes, type........_.._.......... <br /> (Plot plan, showing size of lot,5 location of system in relation to wells, buildings, etc. must be placed on reverst side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit,permitted if public i , available thi�200 f <br /> -sewer s ailable w,i feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size ------------------ ------ ------ ......Liquid Depth...................... ...CK <br /> • Capacity.....................Type------- -_.-.. ..-,..:-:Mate-r'iaI-------- --.,No. Compartments l-----=--•--------- -------- <br /> Distar ce to nearest: Well---------------------- -"_, -------------Foundation.-----.... Line--------- ------ <br /> LEACHING LINE No. of Lines_...... .... ..._--- Length of each lina ........... . ...... ....... Total Length ...... ---- - --- <br /> 'D' Box--.- Type-filter Material............ .......Depth Filter Material------------- ......... ------------------__.......... <br /> r <br /> -Distance to nearest: Well--------------------- ...Foundation-----------------:----- Property Line..._...................._-.-.-----. <br /> il- <br /> SEEPAGE PIT Depth-- .... _.—Diameter--------------- Number--------------------- ---------- Rock Filled Yes EJ No E] <br /> Water Table Depth------- ----------- -------------------------------------Rock Size---------__..........................Well.::: 1-.1 ­­ . <br /> Distance to near -------------------Foundation.......... .... _Prop dine.----......... --------- <br /> REPAIR/ADDITION [Prev. Sanitation Permit#--------.-------- ...... .­­ ......Date------------------------------------------------ <br /> Septic Tank [Specify Requirements ------ <br /> _/........... __------------------ --------------- --------- ......... <br /> �Z......... ... . <br /> Disposal Field (Specify Requireiments) ...... ......&?t6---Al <br /> ........... ......­­­---------­ <br /> ---- --------------------------------- T---------------------------------------------------------------------------------- ----- ......... <br /> ................ ...... -------------------­------- --- ------ --- ---­--------------------------------------- ----- ........... --------­ ------------- <br /> [Draw <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 Son 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 permit is issued shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed------ ................. ....... ..............Owner <br /> BY........... ...... ------- ................ ------ <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ----------- <br /> APPLICATION ACCEPTED BY-:-----Al ....................... .................. ........... DATE ..... <br /> DIVISION OF LAND NUMBER.,.,............ ......... ............................................................... .............DATE------�...�y <br /> I ------ -------- .......... <br /> ADDITIONAL COMMENTS__..-.:`..............-t ---------- <br /> ----- --------------------- -------- -------- ------------------------------------------------------------------------ - .... ... <br /> .. ... ................. . <br /> ------...... ......... ...................E- ------ ........... ...... --------- -----------------I------I <br /> -------------------------------- --------------------•--------I! ........ <br /> ---------------- <br /> .................:.................... <br /> Final Inspe6ion by . -------- ------------------------------------------------------------------ .. <br /> ? <br /> :...... -------------------------- --------- - ---- ------------- ....... ... <br /> EH 13 24F&S 21A77-a-01,1/76 3M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />