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FOR OFFICE USE: 0 <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit NO2..�7= <br /> Date Issued- <br /> ..........................• ...... V' This 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 /> JOB ADDRESS/LOCAT N---6�)3.......5..... <br /> �T.g - CENSI 15 TRACT ........... -------- <br /> Owner's Name..._ <br /> - Z <br /> --- KRA <br /> Phone ne <br /> . ..... . ...... . ............ ... .... <br /> Address. . - - --- -- --- �l ... city.. ... . .. . ... .. ...... ' . 5Z49 i p <br /> Contractor's Named&�; <br /> - -WIlk - - -- -- License # Phbne . <br /> .1 <br /> . . <br /> ---------- <br /> Installation will serve: Residence- Apartment House E] Commercial [] Trailer Court <br /> Motel [] Other--- -------------- ..................... <br /> Number of living units:--_.... Number of b drooms-.1-c2—Garbage Grander./AJ ._.Lot Size.... <br /> 'A -------­­----- -- <br /> Water Supply: Public System and name_ --- ..........I..................... ...................... ------ .Private <br /> Character of soil to a depth of 3 _]at feet: Sand Silt n Clay EJ Ne r []Sandy Loam ❑ Clay Loam <br /> Hardpan E] AclobdGf--1 a, Fill'Material.- ­.. ..Af yes, type------ ------- -------- <br /> - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. mu-0-be-p4ec6d on reerse side.) <br /> f <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public' feet,) <br /> is available within 20 tetJ <br /> PACKAGE TREATMENT SEPTIC TANK [ I I 4--�-- <br /> I -- <br /> SiZ - ­­ ----------------------------------------------Liqui Depth..----- .......... <br /> Capacity----- ------ ----------- ..............No. Compartments—............. ­............ <br /> Distance to nearest: Well--- ...... ... ................. . .,..._.-_..Pr p. Line-.-.-.---.-----------.---. <br /> LEACHING <br /> ine--- ---------- <br /> LEACHING LINE No. of--tines - --- ----------­­-----Length of each line..------..._..---------......-Total Length . ....... ........ ............. <br /> Box-..-------Type Filter Material..----- ...... ....Depth Filter Material-------------- -------i--------- ------- .......... <br /> Distance,to nearest: Well.-....._. ....._;..----.Foundation._.-- Property Line.............. ---------- <br /> SEEPAGE PIT Depth.. -.-Diameter--------- .--....Number-.------------------------------ Rock Filled Yes 0 No <br /> ❑ <br /> Water Table Depth------------------------------- --------- ...............Rock Size,-..........­------------ <br /> .................. <br /> Distance to nearest. Well­-------------------------- ---------I....Foundation---. ---------- -----.-.Prckp. Line..-.-.__-.-._....------... <br /> REPAIR/ADDITION <br /> ine--- -------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#......... - -.-_.-........Date....._..........-._.----�,e-----% <br /> ..... - -- ------ <br /> Septic Tank (Specify Requirements).­J&D-­­.... . ..... ------ ------ <br /> Disposal Field (Specify Requirements)--- ....... <br /> .................. --------------------- ----------------------------- ----------------------- - -------- ---------- <br /> /- --------- -------------------------------------------------------------------------------------- -- --------*-------- <br /> ---------------- ---------------- ....... ------- -------------- .. <br /> -------------- ............................ ....­ ---------- ---------- ------- <br /> ------------------- <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 San 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: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to -Aman's Comp nsation laws of California." <br /> Signed..._ .... .. ------a6aec_ <br /> By................ .... ... .......... .. ... ..... . . ... - - ----------- ----- ---------.Title...... .- ---...--------- --------­----­------ -------- ------ <br /> (If other owne <br /> al <br /> ,fONT USE ONLY R DEP <br /> APPLICATION ACCEPTED BY-------- ------ ---------­ ............. ...........DATE_..._ ------------- . ........ <br /> 10 <br /> DIVISION OF LAND NUMBER.------ ........................... ................ ...... DATE.--------- ---- ...... <br /> ADDITIONALCOMMENTS..............­­----------- .........................­­------ ----------------------------------------------------------------­­--------- -­ �........ <br /> ......................... ...............­­------•------------ - ............. ....... ......... ...... ............. ............ .............. ......... ...............­...­-­--- ------­ <br /> -------------•--------------............­........­-------­­­­­ ........................­................ ......... .................. ........... - ------------------------------------- <br /> ------------- --------------------------------------- ........­ -- ---- - <br /> Final <br /> -----------­­------- -5----- .... -------­------ DaI---.---.-.-.-.----6 )-711. ----------- ---- ----- <br /> Final Inspection by:---­-� ............ ----------------------------------------------------------------------------------- --- A F&S 21677 REV. 7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />