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FOR OFFICE USE: FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- -- ,7a ---- <br /> - - �--------------------- (Complete in Triplicate) Permit Na. -- -.-- <br /> -- -- --------------- ------------------- -------- _ <br /> .Date Issued_�+-����,__ <br /> •----------------------------------------------------- -- This PerrtiitExpires 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. I' <br /> This application is made in compliance with County O inance No. 549 and existing Rules and Regulations: <br /> JOB AD 10 (----- - = ---- —CENSUS TRACT t ----- ---- <br /> tl <br /> Owner's i_ ._ � --.. Phone = <br /> i <br /> ,. <br /> IV <br /> Address------------'------- �-1-�------- ---------------------- - kCi . _ - ZAP s _ <br /> �' -'� '! t License #_. s-3 Phone 6SG16 . <br /> Contractor's Name ------- ------ y <br /> Installation will serve: Residence ❑ ; Apartment House. Commercial Trailer Court ❑ <br /> Motel ❑ Other <br /> t <br /> i ..._ -_ l :Number of living units_----------------Number of bedrooms_ __-Garbage Grinder.--__._-__Lot Size - __.-----. <br /> __.____..___Water Supply: Public System and name -__._._' ---------------------------- ----- -------------2--Priv_a-t_e A: <br /> _--' <br /> ❑ <br /> Character of soil to a depth of 3 feet: Sand Q Silt❑ Clay ❑ Peat❑ SaandyLoam^❑ Clay Loam ❑ ' <br /> Hardpan ❑ Adobe Fill Material-------------- yes, type-------------------- ----_------- 1 <br /> (Plot plan, showing size of lot, location of-system in relation to wells, buildings, etc..must.be placed on reverse side.) W <br /> NEW INSTALLATION: (No septic tank'.or-seepagerpit permitted ifpublic sewer is available within 200 feet,) ' <br />-__PACKAGE TREATMENT [ ] f SEPTIC TANK -Size--------------------- _____________________liquid <br /> � t - . - Dept <br /> h_-_-91--------________ <br /> Capacity-�-�C - -Type -- -- Matarial � ---- - No. Compartments.__. -- _ <br /> �--- <br /> Distdnce:to nearest: Well. ---------------Foundation___ _ -------Prop. Line_--$-r_8-4~--£ <br /> LEACHING LINE [�j� No. of Lines-.___./__----------__--- _Length of each line._A�_,_-j_---,.,____.._Total.Length.------��_Q----------_--____ <br /> # t 'D' Box............Type Filter Material 31,0 ,Depth Filter Material .___-!_.___._ __--__.___._____-__ __-_____ - <br /> Distanceto nearest: Well- f ____l/_____.-Found ation._&�,O_.�___-___-___.Property Line._ _ ___ _________________ <br /> SEEPAGE PI �---..- <br /> T Depths__S____._Diameter._.��r Number_____ x .-.f� Rock Filled Yes) No r. <br /> --- --- <br /> ---Water Table Depth -- �.__ -'- --�```'� ._.Rock Size _�1V.�_ _ . - � _- ; � { <br /> r .,..� _ -.a- , <br /> [ Distance to nearest: We1i_-____ __: -_..._____..____.F.oundatiori._,_r __ _____________ Prop; Line----------_!" - <br /> REPAIR/ADDITION-[Prey-Sanitation-�Permit-#---------- ----=-----=-------------------- ------------------------ ^,r._.-..']_ .� <br /> Septic Tank (Specify Requirements)----- ------------ <br /> Disposal Field (Specify Requirements)-------------- --- ------- ------ --- ------------------------------------------------------=-------------- <br /> ------------- ------ -- ---- ----------------.-------------------------`-----------------------�--------- ---------- - ----------------------- -- ---- --- ------ -- --- <br /> ------------------------- - -- -- -- - - -- --- ----------- ------ <br /> 1 _ <br /> {Draw existing and required'additian'on reverse side) 4-1 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun <br /> Ordinances, State Laws, and Rules 'and Regulations of the, San Joaquin Local Health District. Home owner or licensed agent ; <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 al' <br /> to bet me bject to W.cl kma 's Compensation laws of California." <br /> �-eC- <br /> Signed -'�- ` Owner # <br /> - <br /> BY-`---------------------k--------------------- / ----- ---------'------------- ----------------------- <br /> C! <br /> (If other�.thTitle t <br /> an,owner) <br /> 'FOR DEPARTMENT USE NLY, <br /> APPLICATION ACCEPTED BY------------------------ -- / - --------DATE ------ - <br /> DIVISION OF LAND NUMBER ` DATE - --------------------'-------- -- ------ ' <br /> ADDITIONAL COMMENTS__ G' --------------------------------- ; <br /> �_ <br /> -------------- ---------- 1------------------- -- -------------------------------- --------- ------------------------ ---- ------------------------------ ------------------- <br /> -- ----- - <br /> =------------------- ---------- ----------------------------------------------------------------------------------------------- <br /> Findl Inspection b . - -_______-_Date. __Y:---- � O <br /> ------------------T- <br /> --- <br /> EH 13 24 µSDISTRICT F&s 21677 REV, i W <br />