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i <br /> FOR OFFICE USE: APPLIC#TION FOR SANITATION PERMIT <br /> --------------------------------------------------------- "tC4mptete in Triplickte) -4,4,-19 <br /> Permit No. <br /> �. <br /> `` Date Issued -----'v -- <br />' _________________________________________________________ This Permit Expires 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 <br /> described. This application is made in comp.11ance-with Coun yd.Ordinance„No,..5A9 and existing Rus�and-Rglalld'fi <br /> JOB ADDRESS/LOCATI CENSUS ACT <br /> Owner's Name ----------- - --- --P one 47F -- - - -- <br /> rr9 <br /> b_ -- <br /> Address ----------------- - -- -- --------- - - --------- -- -- - - ItY --- <br /> -- - -- ----- ----------------------- <br /> Contractor's Name ---------------- --r----- --- ----- ---- ----- ------ --4t4 ?.License # --- Phone -w-1 ?6------ <br /> Installation <br /> . —Installation will serve: Residence VApartment House❑ Commercial:OTrailer Court ;❑ <br /> Motel ❑Other --------------------- .t <br /> AC <br /> Number of living units:---_-1---_- Number of bedrooms -_.?_-_-Ga age Grinder -CLot.S/iz'e -----I ---- -- ----..._ <br /> Water Supply: Public System and name ------------ ---------•-`------.._..-----_--_----q <br /> -'L.dJ_ -----1.l3_Y!F---------------Private ❑ <br /> Character of soil to a depth of 3 feet Sand❑ Silt❑ Clay-(:]' Peat 0 Sandy f,2 sClay,Loam:❑ <br /> Hardpan E] Adobe Fill Material ------------ If yes`type --__-- -------------- <br /> {Plot plan, showing size-of'lotocon•of system in relatidn>to wells, buildings,-etc .must be placed on reverse side.} <br /> NEW INSTALLATION:: (No septic tank or seepage pit permitted if public sewer is ay�,ilable within 200 feet,) f� <br /> PACKAGE TREATMENT SEPTIC TANK I Si e___--__-_ Liquid Depth -- -.....------ <br /> I ] _ Win/_�._ --------( <br /> �ty -fP�- Type -- - - �.-- a --- Material--�-:G•--!-- No. Compartments <br /> t ---------------- <br /> s <br /> Distance�to,-ne res Well ------- ___ ___ ______________Foundation -----40-1------- Prop. Line -_lQ_........... <br /> LEACHING LINE [ ] No. of Lines ------�;---------- tLength of ach line.-----_7 _---_.------ Total Length ,__,�.5" ?------------ <br /> 'D' <br /> ----- ---- , <br /> 'D' Box ---�- Type Filter Material -�----Depth Filter Material ----- -- ­-------------- ' <br /> Distance to nearest-. Well ------------------------ Q <br /> {------------------- Foundation -.-1 _---_-_-- Property Line -10-'.--------- <br /> SEEPAGE PIT Depth ----2-:m-------- Diameter <br /> ] p � � � -- ----- ---------------�/--��__ Rock Filled Yes No <br /> Water Table 'Depth �'�-- -Rock Size _�ly-----���)"-- r <br /> Distance to nearest: Well ----------------------------------------Foundationld--------- Prop. Line -._ ._-__-------__-- <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit#--------•----- ----------------------------- Date ----------------.----...--.-.__-_-1 <br /> SepticTank (Specify Requirements) ---- ----------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal <br /> ---------------------------------- ------Disposal Field (Specify Requirements} --------------------------------------------------------------------------------------------------------------------- ------------- . <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- ------ <br /> ••-•(Draw existing-and-required add ition,on.xeverse,side)_, <br /> I hereby certify that I have prepared this application an��thatt.1the work;will`be.done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San-Joaquin Local Health District. Home owner or [licen- <br /> sed agents signature certifies the following- ' <br /> "I certify that in the performance of the work for which this permit is issued, I shall not,enrploy any person in such manner <br /> as to become subject to,Workman's Compensation laws of California." <br /> Signed ----------- ------------------- ------- --- Owner <br /> BY ----'--- Title ----- ------ ------------------------------------------- <br /> (If other owner} <br /> FOR DEPAitT,-MENT�IJS �O14, f <br /> APPLICATION ACCEPTED BY DATE -.- .-`. ".' r <br /> NG <br /> ADIDIITI ONAL OIMM NTD-- - ------------------------------- DATE------------------------------------------- <br /> F <br /> ------------------ -- - <br /> ------------(a -- -- -- <br /> -------------------------------------- <br /> ----------------------------------------- - <br /> ----------------- <br /> ---------------------------------------- <br /> -------- . <br /> --------------------------- -- ------ -------------- --- ---- -------------------------------------------- <br /> FinalInspection by: ---- -- --- ------------------------------------------------------ ----------------------------Date -----------------' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br /> I <br />