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l"nR OFFICE USE; FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT •� . ' <br /> 11 (Complete in Triplicate) Permit No7r:n$r.s�....-- <br /> _,............... ------------- ............. <br /> Date Issued-,/r_;Y <br /> .........- --••.................. ............ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District fora permit,to construct and install the work herein described... <br /> This application.{is.m.ade incompliance-with Cou ty.-grd.i ance.•No, 54:9 and existing.,Rules anal e%gulations:_,.,_- <br /> JOB ADDRESS/LOCATION '......:... .. <br /> 4! .. , .: . . .. ...-- ---- -/--- <br /> --.CENSUS T <br /> ReACT. -1 <br /> RhanOwner s Nome. , ' <br /> .. PAddress --- _4 � ------. . --- City <br /> " <br /> a <br /> Contractor's Name- <br /> s r : <br /> ...... :.... .. ... ....... -License-4 - .. .Phone.:........... ................ <br /> Installation will serve: ) Residence jAportmentHouse 0i Commercial 0 Trailer Court ElMotel ❑ 'Other_...... <br /> r Garbe a Grinder--.'......_.Lot'Size------.__� <br /> i 7 t, Y/. j?r� <br /> Number of living units:........... ...Number of bedrooms.-... _.. g= __._ . . -. - .---p-..,.--. - _ .. . <br /> I /,, h" :.. <br /> Water Supply: Public System and name............... . _....0 .� <br /> �` _Private ❑ <br /> � i <br /> Character of soil to a.depth of,3 feet; "Sand 0 Silt ❑ Clay ❑ dept ❑ Sdndy Loam ❑ Clay Loam <br /> i [ Hardpan❑ Adobe,® Fill Material_ ---. .i..If yes, type------------------------- <br /> --- <br /> (Plot plan, showing size of lot; location of system in relation to wellYs,ibuildings,`etc, musf be placed on reverse.side[ <br /> NEW INSTALLATION: i <br /> ;(No'4septic tank or seepage pit permitted if public sewer is available within''. <br /> PACKAGE <br /> . <br /> I PACKAGE TREATMENT [ ] :;'SEPTIC TANK .......---, 3 .-------_- r.-�.Liquid Depth... .. O <br /> 8I y C✓ .... 3 <br /> i L <br /> Capacity fL' •�f' fj.' 3/Yp e. "al.. . _No. Compartments_ <br /> _, C <br /> Distanceto inearest: Well.-'i y Foundation .:_ + Prop. L ne <br /> LINE [ ;] No. of Lines... . .....-•-- � I � .r ng --- <br /> . .......�Len"Length -of each fine.-=.'.>� �. :"�.:._'_,-...: Total Len _ <br /> LEACHING � .�. ��.. ...-...-. <br /> if D' Box.:. ... ...Type Filter Material 6.-. _ i.Dept}r Filter Material- -n,.... ' ---.....;..---------- -- ----------------- <br /> Distances <br /> ---------- ----- <br /> Distance to.nearest: Wel'l------------------ --------- Founddticsn.-'- " -. - _ p ----------------------- <br /> SEEPAGE <br /> ------ <br /> :. i� Pro erty Line,. o <br /> SEEPAGE PIT [ ] Depth---x:..__ .....Diameter....--= <br /> :II .• Number ct--------------------- Rock Filled lyes ❑ No [] . <br /> f1 <br /> s Water, Table 'Depth----------------------------------.--------...----•----.Rack Size......- - --- --....................... <br /> .... <br /> Distance to nearest: Well............ _ -----Foundation............... ..........Prop. Line---.--- <br /> l REPAIR/ADDITION (Prov. Sanitation Permit#--------------- ------------------ ---- ----------Date--.-.---:................ <br /> 1-- - ------ ----) <br /> Septic Tank (Specify Requirements)............ ....................... :. 1............................... <br /> Disposal Field (Specify Requirements)------------------ .---- ------ :...-..:.... 9.. <br /> ---- <br /> i� .. i _ <br /> ------------- <br /> �. (Draw existing and required addition on reverse side),: f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin"`County, <br /> I Ord{inances, State Laws, and,'. Rules -and Regulations of the -San Joaquin Local Health.District, H,onid.owner.or Jicensed'agents <br /> ` ; ;\ <br /> signature certifies the following' : <br /> "I 1ertif that in the' it <br /> Y performance of The work for which-#itis-permit is- issued;'-i shall- not.emplay aq}t_p�rsori�i.n such.manner as <br /> " to become sub" t 1 i <br /> n's Comp nsation laws of, California." <br /> . <br /> Signed- -- <br /> - _iOwner <br /> By-!...........:.:........ ---- -i----- -- -.-- Title..- -..,.......... <br /> l7 <br /> (!f other than owner) <br /> I� OR OEPARTMT JUSE ONLY <br /> APPLICATION ACCEPTED BY..': <br /> -•--- . .. -�--- -•---------- - .................DATE <br /> DIV <br /> ION <br /> 3! -moi-. ��. - _: DATE:.. <br /> -------- <br /> ADDITIONAL ONOAL OMMENTS.E�... ..--- - A <br /> -- r.. -- .r .. <br /> ----: .. <br /> ---------- •---- ------------- ----------- ------------------------------- <br /> ' l <br /> ............... <br /> �. -------------------------- -------- <br /> --..... -I/- �� �.y: <br /> Final Inspect"on b - k -- - ' Date <br /> EH 13 24 �� SAN JOAQUIN LOCAL HEALTH DISTRICT F85 71677 REV. 7/76 3M <br />