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FOR OFFICE USE: FOR OFFICE"USE: <br /> 4 APPLICATION FOR SANITATION PERMIT <br /> ----------• ------------- <br /> #lCornpiete in Triplicate}_ <br /> ; V --- - -- ------------- �- <br /> r <br /> This PernoIxpltres 1 Year From.Vtsts.issued; <br /> ---------- <br /> Applicationis 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 Circli arlce No:5 d)existing Rules and Regulatiort :" , <br /> JOB ADDI2SS1L. o�'� ._.y_ •--- _ �,------------ CElVS45.TAh:I ,- - <br /> OvMer's N€ ::.. 4 =-- ------------j -----.-. -- -� = - -.•, -Phone _- <br /> -- <br /> Address---- -., -- ----- Xr777- p <br /> Contra 's Name. = .. license# Phare <br /> Ins#ssllation will set": Residence[� Apartment House❑ Cflrlvtial ❑ Trailer Court ❑ <br /> Motel, ] Othor = ;j <br /> js- <br /> Number of living,units:-.--_.--- -_Number of bedrooms Garbage Grinder_,, --------Lot Size-- .-_---- -_- ----- <br /> Woer Supply: Public System and name - ... -- -------------.............. .--- ------ - - <br /> vate. <br /> -Character of soil to a depth of a3 feet: Sand_❑ ;Silt❑ Clay❑ Peat 0 lay Loatnb <br /> Hard" ❑ Adobe❑ i:ill Ma4erial lf'yes,toe-- • - <br /> (Plot plan, showing size of lot4 location of system in relation to wells, buildings,etc.Aust be placed on reverse side.) <br /> NEIN INSTALLATION' (No Septic tank ac seepage pit permitted if publicewer ls: bfawithin <br /> 200-feet,) ,. <br /> Size -,- ------ <br /> PACKAGE SEPTIC TANK f ] ..•ti uid De th <br /> --------- <br /> Capacityrtents- ------ .._. <br /> Q <br /> -------- Type-----------------------Matas] <br /> Distance to nearestlAl$II_.. - - our►datian -- --- Prop. Line..,-...... 5 <br /> LEACHING LINE: [ ] No., of,Lines--------- - - --------Length of each,line _ - . ----Totgxl Length.,---- - --- --- -- -- -. <br /> 'D' Box------------Type Filter Material------------ ..-Depth Fltfor ter:al ,: _ -�-. -- <br /> to nearest:Weil----------------------------Fourla#ion------- - __----__ _Property Lies. ._r_-_. <br /> _ ------------ <br /> Distance .r <br /> SEEPAGE PIS' [ ] Depth-- __ __Diameter-.--- ----- -----Number �------_--_ :�- Rotk Filled Yes No,; , <br /> l.J , <br /> Water Table Depth'. _. o <br /> f <br /> f <br /> Distance,to nearest:Well---.---------------------------------------0ountl`cltion -..........--------".Prop. Line-.----------- . <br /> REPAIII/ADDiTION (Prev. Sanitation Permit#-------- ---. ----- D ) <br /> Septic Tank (Specify Requirements)-_____ F <br /> _ <br /> va <br /> Disposal Field (Specify Requirements).____-- - ���� -���--• ' <br /> ---- -----.--------------- ------------ ---- ------ -- ----- --- ---- • ----------------------- -------- -- - <br /> (Drav existing and required additlon°tin reverse sid e _ <br /> I hereby certify that 4 have prepared this application and OW"the work will be done in accordance-with San Joaquin County <br /> Ordinances, State Laws, and Rules and, Regulations of the San Jo vin Local Health District, Homq owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in t1w-performance of the:work fog which this permit is IssuiW I sW.not etinploy cl p son in sucl6 tlotrnner:as <br /> to become subject.to-Workman's Compensation Taws of California:.' <br /> Sighed ---- ---'b 7-• <br /> Owner .... <br /> B - ----------------------- <br /> Y T. "Y.,. ., -_ <br /> iff-other than owner) <br /> "t DEPARTMENT'USII ONLY` <br /> APPLICATION ACCEPTED BY---- --Alo. -- = - ----- - .. DATE. r <br /> DIVISION OF LAND NUMBER--------------- ----------- ------ ...........DATE -­------------- , ......................... <br /> ADDITIONAL COMMEhiTS--------------------------------------------- .. <br /> ---- ............................. - ------ ---------------------__---- .......-............................... ------------• - ................ -- •,-- --- --- - -- --- <br /> . - . <br /> .. • --- -- -- -- -- -- - t_NFinal lnspectlon. br -•--_ •-- -- -------- --- ---- -,.��� --- - ----- --- .. .._.._ __._. _._ . ----- ---Date: ..-----.+ia 2a lOAQUIN LOCAL HEALTH DISTRICT <br /> 1"21677 REV.7/76 3M <br />