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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � <br /> --- ---------- ---------------------- Permit No._ a_'-5V 3 <br /> (Complete in Triplicate) <br /> --------------------------------------- --- ------------- } <br /> Date Issued..!-Y/T9 -- <br /> This Permit Expires 1 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 /> JOB ADDRESS/LOCATIO ,a.- - / =-------------------------- - .CENSUS TRACT <br /> ( s <br /> Owner's Name.----- _ s `- •- - `�� • <br /> --- <br /> ------------- ------- ----------- <br /> � <br /> Phone <br /> -- p _---- -------- ---------- <br /> Address <br /> ___ -- --- Ci+Y_ .--- -- ---Zi <br /> r's Name-: = ---- _License # _ _Phone----------------------------------- <br /> + <br /> Installation <br /> ------- --------------- -- <br /> Installation will serve: Residence Apartment House.E.] Commercial 0 Trailer,Court: ❑ , <br /> t ..... .p -•----Motel Other:__: - h ' i_ :. .� <br /> Number-of living units:-_,___.__�.___Number_of.bedrooms_.._________Garbage Grinder =-4- lot Size.-_.__ __ -- __.____---------- <br /> ___. <br /> Water Supply: Public System and name .: ' K --t--�---- ---Y�---- :-- --�- :, ---------------- Private <br /> Character of soil to a depth of 3 feet: ` Sandy❑ SiltJ❑ Clay❑ Peat [} Sandy Loam [� Clay Loam ❑ ' - <br /> 1 { 1 <br /> t p .. E �M7at r Y YP <br /> . Hard an Adobe� r Fi11 Material__ ._.__-___If es, fi e._____.___ <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 '` ------------ -----Liquid 'Depth.__.____________-______ _ <br /> [ ] [.] Size----=--------------=------'- <br /> -------------- <br /> ' <br /> Capacity- -- -------Type,_. �` -s--- Materiial-----=-=--- ------.--No. Compartments-------- ------ <br /> Distance to nearest: Well--------=------------`-------------- <br /> ---------------------Foundation t--------------------_---Prop. Line--------`------------------ <br /> }. <br /> LEACHING LINE, [ ] Na. of Lines_;._,_. ,-----.__.__,^-------Len gth of each line--------- .,.__,,__:..,___:______Total Length-------------------------- <br /> D' Box--,------ _Type Filter Material--------------------Depth Filter Material---------------------_----------_---------------------------------- <br /> Distance to nearest: Well-----------------------------Foundation-----------------------------Property Line---------------------------------- <br /> SEEPAGE <br /> ____ _____--_SEEPAGE PIT [ ] Depth----'___.-`.__.Diameter--------_------_----Number---:________.___'__________. Rock Filled Yes El No <br /> Water Table-Dep --- <br /> ' Depth � - ----------------------------------=-----Rock Size--------- - --- --- ------ , <br /> Distance to nearest: Well----------------------'--------------------Foundation-------------------------.Prop. Line- --------------- <br /> REPAIR/ADDITION (Prev, Sanitation Permit#_______________ - , <br /> ----- Date----------------- = ) <br /> Septic Tank [Specify Requirements)--- <br /> --------------- - = ------- =--------- ------------------------------- - = -------- <br /> . _ ------- <br /> --------- ------- <br /> Disposal Field (Sp cify Requirements)---- - <br /> d _ ---- -- ------------------------------ <br /> - -. .- <br /> --- --------- -----------------------------------------------=------------------------------------=------ ---------------.----------------- -- ----------------- ------------------- ---- -------------------- <br /> r (Draw existing and required addition on reverse side) <br /> ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin aCounty <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: z <br /> "I certify that in the performance of.the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman' Compensation laws of California.". i <br /> Signed ------------ ,'------ -------------- ---- ---- ----_-.-- .--Owner _ .. <br /> I <br /> By--------------------------------------------------- -- ----- -- -- _._:Title ,.. <br /> (If other'than.owner) <br /> I FOR DEPARTMENT USE ONLY <br /> DATE.-- <br /> APPLICATION ACCEPTED BY <br /> DIVISION OF LAND NUMBER ------------ --- ------- ------ --- ---- ----- DATE..--------------- <br /> ADDITIONALCOMMENTS------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------.. <br /> t <br /> ------------- -------- ---------------------- --------- ----------------------------------------------------------- ------ ----------------------------------------------------- --- ---------------- <br /> ------------------- <br /> or <br /> ------------------------------------ - - ---------- ------------------ -------------------- --------------------- <br /> -------------- <br /> Final <br /> - - ------------- <br /> rFinal Inspection by <br /> EH <br /> G <br /> 13 24 SAN JOAQUI OCAL HEALTH DISTRICT Fas 2t677 REV. 7/76 3M <br />