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FOR OFFICE USE: FOR OFFICE USE <br /> it APPLICATION FOR SANITATION PERMIT <br /> -------------------30...... ........................ Permit <br /> (Complete in Triplicate) <br /> ---------•-----#------------­----- --------- Date Issued <br /> • <br /> ............ ....... ............... Thi's Permit Expires I Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No, 549 and existing.Rules and Regulations: <br /> CENSUS TRACT��rGr'�' ...----------------- <br /> . -------- <br /> JOB ADDRESS/LOCATI N------ ... . - -- <br /> ------ <br /> Owner's Name.....O. L511rL4--V-. <br /> ..------t-- --------------------- Phone.- -4 ..... ..... ... <br /> -------------- ------ <br /> City­����--­----------Zip <br /> Address---a�03..?. ......�,x�- ' W�LO,/- -��- - -------- <br /> Contractor's Name..---;;". ......... ........... License ....-Phone.., <br /> Installation will serve: Residence gr'-'Apartment House ❑ Commercial ❑ Trailer Court El <br /> Motel ❑ Other­­............. - ------------------------ <br /> �ber of bedrooms-�-7-....Garbage Gindex-._..--- ---Lot Slze­:��/ <br /> yC .....Number I ----------- -- <br /> Number of living units:------ <br /> ................... ......--------Private El <br /> Water Supply: Public System and name.-...(:?�­ <br /> Character of soil to a depth of 3 feet:.. Sand E] Silt F1 Clay Ej Peat E] Sandy Loam Clay Loam El <br /> Hardpan L] Adobe Fill Material . .... ....If yes, type....--.__--------------------- <br /> (Plot <br /> ype...... ------------------ - ---- <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: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,( <br /> PACKAGE TREATMENT SEPTIC TANK 77----------------..-.LiquTj Depth.:._:'------------------- <br /> -ri ----- -------No. Compartments.......C.. .............. <br /> Capocity1o?,ap--------Typep Mate <br /> Distance to nearest: Well.-'.................. ­­................Foundation-'—/ ------ ­'Prop. Line.... ------ <br /> LEACONG LINE No. of Lines:'........- ------- ..... Length of each hnel-�----1?•�------ --Total Length ------ <br /> 'D' Box..-A777-.-Type Filter Material.41ROGk..Depth Filter Material.- 0" ................. --------- <br /> Distance to nearest. Well--------------- Foundation-- R­e-')------- ­....Property Line.......­­-- ------- - ------ <br /> it......... . <br /> SEEPAGE PIT Depth..02 Rock Filled Ye No <br /> Water <br /> ........ Diameter.... ......Number. <br /> ......;-------------- -------- <br /> Water Table Depth........./ Size.- - . ...... <br /> .......................Rock Si -------- <br /> Distance to nearest: Well---------­---------­-­ .............Foundation.-.---.-.------..Prop. Line.­J---------------­.... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- -------- bate----....:----- ------- ---------- -----------) <br /> Septic Tank (Specify Requirements)--------- - ..................... -----------......-.------=--- ....... ..-------- . ..... --..----• ....----------­­........ <br /> Disposal Field (Specify Requirements)-- --------------- <br /> ------------- - ----------- ---------------- --------------------------------------------- --------- <br /> ................ <br /> ----------------- ----------------------­ �...... ....­­--------- ------------:---------- ----------------------------------- ........ ...... . ....... <br /> ---­---------------------- ................. ----------------------------------------*�-- - ------I----------------- -­------------- .............­­­------------- ...... -------------- <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 Son 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: 11. - a <br /> "I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in such manner as <br /> to becom bi e t tokmant's Compensation laws of California." <br /> ­� L ..................Owner <br /> Signed— ro" . . <br /> ............. --- - ------------­-------- <br /> By------ ------------------- - -- - Title <br /> ----- <br /> (If other than owner) <br /> I FOR D.EPARTIKEWi USE ONLY <br /> '-APPLICATION ACCEPTED BY ................. - --------- ........ ---- ---------- ----------- ­. ......... ..I.......­ <br /> DIVISION OF LAND NUMBER:V----------- .................................................. .. -...DATE ­---­-----------�------- ---- ------ --- <br /> ADDITIONALCOMMENTS. ------------------------­----­ ---------------- ..... . ......... ........... f--------- ----------- <br /> ................. .........I—......... -------- ................­­........................... <br /> .............. . ...................... ------------­-------------- <br /> Y­N­ ------ <br /> --------------- ----------------------- ... ---------- ----------------- ---------------------- <br /> atlk� <br /> ------------------------------------ <br /> Final Inspetiion by.-.... ..... <br /> • EH 13 24 N LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 W <br />