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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT .5— <br /> -------------------------------- ---------­.......... ­ ( C :1 Permit No.=-7e— <br /> (Complete in Triplicate) <br /> --------------------------------------- -------------- <br /> Date issued/.,*.=,1C5"':.7��"l <br /> .................... ........I...... ......... ---------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the.Son Joaquin Local Health District for a permit to,construct and'install the work herein described. <br /> This application is made in compliance with CoLinty Ordinance No. 549 on.d ex4stingl Rules and Regulations: <br /> Ce ?moi __CENSUS TRACT............. --------- <br /> JOB ADDRESSAOCGION.... ------'-- ........... . . ....................................... <br /> Owner's Name.... <br /> . . ... <br /> ---------- <br /> Ph9ne_,,ZM3- - <br /> / <br /> Address.. _ _g _o . _A_0---- ---- ......._-City <br /> Contractor's Name ---------- --------- --License P h a n e <br /> Installation will serve: Residence E] Apartment'House E� co�r�mercial ❑ Trailer Court <br /> ❑ <br /> - A -------------- <br /> Mote Other- <br /> Number of living units: ---------------Number o lrol�olms_ C. .....Garb6g,e Grinder-----------.-Lot Size-__-_ ----- -- <br /> Private <br /> Water Supply: Public System and name....... .__.. .............. ...... <br /> ----------------- - ------------ -------- <br />-Character of soil to a depth of-3 feet; I Sand Silt E] Clay E] Peat.. . Sandy Loom [] ,Clayyjoarn El <br /> Hardpan 0 Adobe 0 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 fee <br /> ............ .. ......Liquid Depth <br /> PACKAGE TREATMENT SEPTIC TANK IV.5-1. <br /> Capacity/ 0.0 - Jy' pe. - tMaterial Compartments.............C? ..... .. <br /> 07") 14 <br /> Distance to nearest; Wel I Foundation.. Prop. Line-_.S.'. <br /> ............ <br /> Length 'ofeach -----Total Lenwh ----------- <br /> LEACHING LINE—M-111 Na: Lines_.___.-.----------------- <br /> .. 't , 'L, <br /> tj -D" 'Bo i Iter.Mciter.1a I J�?04k.be' th Filter Mat,eriql /A..... --------- ------- ---------- -------- <br /> 36 x�. Type F p L <br /> b� e <br /> ---Property Lin <br /> bistdnce,to nearest: Well___--F-4)- -------- Founclation,/4 <br /> Rock Filled Yes E] No <br /> SEEPAGE PIT Depth_`�.... .......Diameter........ ----- ----Number ........... --------------- -- <br /> Water Table Depth--------_--------------- ........._---------------Rock Size.-__-.-"' --------- <br /> .... ----------- <br /> Well. --- ------Foundation_-... .... ... ......Prop, Line------- -- <br /> Distance to nearest, -------- .............. ....... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------- --------- ..... ---------------Date--- -_.._._._--..-----.;f--] <br /> 0 <br /> Septic <br /> _- -------- <br /> Septic Tank (SpecifyXeIqu'ir'6ments)---- - - -- ---- ----- <br /> - <br /> Disposdl Field (Specify Requirements)-.- ----------- ------------ -- --------- ----------I------------ ..... ------ <br /> ---------- ----- ....... ........... .............. <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 Son Joaquin Local Health District. Home owner or licensed, agents <br /> signature certifies the following: <br /> 64 certiN. 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 man' C pensati IdWs of California." <br /> bec - ct to V"jor man's om on . J�- <br /> I Signed__. ......... ------ --- ----------- �-.'__Owner <br /> .................... <br /> 44 .,Title--- <br /> ­­­­ ..........­ <br /> By---------------- ................ <br /> ( other r) <br /> I a er than owner] <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. <br /> ... ........... <br /> ....... ....... .. - -------DATE <br /> ... <br /> ------------ <br /> ..-- <br /> .... ........ . <br /> DIVISION OF LANDNUMBER. . ...... _DATE--------------------- . .. <br /> ADDITIONAL COMMENTS----- .......... . .... ..... ......... .......... ..._.... ------------------------------ <br /> - <br /> .............. <br /> ------------ <br /> ........................ - <br /> ----- ------------------------ --- <br /> ............. <br /> ------------------------------------------------ ----�: --------------- <br /> ----------------- <br /> ------------- -------------­:-------------------------- ----------- <br /> ------------------ ------- - ----------- <br /> ......Date.. 7 <br /> Final Insp6ciion by:.... ........... -------------- ------------ ---- <br /> ---------------- - <br /> -------- - - <br /> FILS 21677 REV. 7/76 3M <br /> FH 13 24 SAN J OAQUI LOCAL HEALTH DISTRICT 1:h <br />