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FOR OFFICE USE: FOR OFFICE tom' wr;. <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------- <br /> �[ <br /> (Complete in Triplicate) �Et No _.-_ 2'-x <br /> - ------- - -- --- --- ; <br /> Date 1404444jook ..� <br /> This Permit Explres.1 Year From Date Issued =� <br /> Application is hereby made.ta the San Joaquin Local Health District for,a permit to construct and instal ti wat'i twein de <br /> This application is made in with County Ordinance No,549 and existing Rules and PAW <br /> JOB ADDRESS/L TION _-- - -. _ .-- T 'f ..-.. - <br /> - -- - --- -- - --- <br /> Pye_-.-Owner's Name. ------------------ <br /> Address C � � C <br /> Zip� ^ MContractor's Name-- / .__--License ----------------------- <br /> �. r -----:!5.r- <br /> dInstallation will serve, ence Apartment House.❑ Commercial ❑ Trailer Court <br /> Motel ❑ Other------------------------ ----- --- <br /> Number of living units:-_ __.--- -.-Number of bedrooms.___ . Garbage Grinder---------—Lot Size._ -______.------------ --------___----------------------_ <br /> Water Supply: Public System and name---- ----- --- ---- ----- ---- -- ---- --------- ----- -------- ------------ -----------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam <br /> Hardpan Q 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.) .. <br /> NEW INSTALLATION; (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> y PACKAGE TREAT' IST [ ) SEPTIC TANK [ I Size-----------------------------------------------------------Liquid Depth-- _.__ - w <br /> Ca acit a-_. Material---------------------,_ . No. C9om artments-.- <br /> p Y/,?M_ - -- p <br /> Distan tonearest:Well. �G ......................... Prop. Line_<�, <br /> Foundation __ -__ _ <br /> F LEACHING LINE' [ I No. offes_-_ _-________________Length of each line--V------------------.--.Total L t gth..a x_ <br /> 'D' Box -----Type Filter Materia(-- ---Depth Filter Material--- ., <br /> Distance to nearest: Well-----------•-------- ------Foundation------. ------ -----------Property Line.-- _._ ____--- .- .._ -- 1% <br /> SEEPAGE PIT [ ] Depth----- --------D.iamEter---------------------Number-------------------------------- Rock Filled Yes [], 1 <br /> Water Table Depth-------------------- _- -•----- - -- .-Rock Size--------- - ---- - <br /> Distghce.to neafestE Well--------------------------------------------Foundation------- -- -- ----_.__Prop. Line.;_ <br /> REPAIR/ADDITION (Prev. Sar itation Permit j#------------------------_------- ------. -----.Date_ ..------..-------------_-------.---- ---._) <br /> Septic Tank (Specify Requirements) ---41--_`K--t --- -= - ----------------------------------------- --- ---- _---- ----- ------:- ------ <br /> Disposal Field(Specify Requirementsi-_'i_-_-------------- -- ----------- ----------------------- <br /> -------------------------- ---- <br /> -----------_-__--____ __--___F__-- :.--------- _ ___ _ --------_--------------- ------------------ <br /> ----------------------------------------- <br /> _ ______ _ _------------------------ _-_-_____----.---------------------- _ -.._---_--_ ___-. --_-. __ --___. __-_-_-._--- <br /> :- (Draw existing and required addition on reverse side) <br /> I hereby certify that,'l +spwed this application and that the work will be done in- accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules &W-Regulations of the San Joaquin Local Health District. Home owner-or licensed agents =' <br /> signature certifies the following: . <br /> "I certify that in the performandb.of the work for which this permit is issued; I shall net employ any person in such manner as <br /> to become su4;ect'to W ktn ' Compensation laws of California." <br /> Signed- ' ._- ------------- -- =------------------------------Owner <br /> BY <br /> -, - -----------Title------- --- <br /> (If <br /> other than owner) <br /> _ - --- FORD ARTMENT USE ONLY <br /> APPLICATION AC -RY_-9 ` DATE.12 <br /> DIVISION OF LAND NUMBER._-- -------------- a�-- --- --•:-DATE----------------------------------------------- <br /> ADDITIONAL <br /> - -- ---- <br /> ADDITIONAL COMMENTS---------------------------------------- ----- -------------- ------------------ ----------------------------- - -- - ---- <br /> ----- ------------------------------ -------- ------ ------ ----- <br /> ------------ <br /> ------------------------------ _: ........... --------- <br /> ------------------------------- <br /> ---- <br /> - • ---- ----- -- - ---- -- ---DateFinal <br /> E�H 13sa SAN JOAQUIN LOCAL HEALTH DISTRICT, Fas elan REV. ���d 3M <br />