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FOR OFFICE USE: <br /> FOR OFFICE USE. <br /> .. ..................... ........... ... APPLICATION FOR SANITATION PERMIT <br /> .......................__ I (Complete in Triplicate) Permit NoAr—_ <br /> .................... <br /> . .............................. .. ........­...... ...... This Permit Expires I Year From Onto Issued Date <br /> Application is hereby made to.the San Joaquin Local Health District for a peimit to construct and instd1l. the',work herein described. <br /> This application is madeincompliance with County Ordinance a. 9 and existing <br /> and Regulations: <br /> JOB ADDRESS/L'OCATION.-,...... <br /> Owner's ....... ........ ... . ... ........... ...................... ........--CeNSUS TRACT......:..............11........ <br /> 6Norne......- " 1___1 <br /> ... ........ . <br /> ....... --­------­ ...... ......................Phone... ............ .......... .......... <br /> Address43 ) <br /> 4.. ......I - _...._ .......• _ <br /> Contractor's NcI 04 .. ............ ...... City.................... ---------------- - *....zip_:........ <br /> . ... . . .... . ........... ........License Phone. <br /> Installation will serve; <br /> Residence � Apartment House [] Commercial 0 Trailer Court El <br /> Motel ❑ Other.. . <br /> ........................... .... <br /> Number of living units:....... ........Number of bedro MIS Garbage Grinder—... Size <br /> ........................ <br /> Water Supply: Public System and name <br /> ...... ..------------------ " . . _ . ------------- -------------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt E] Clay E] Peat n Sandy Loam C3 Clay Loom <br /> ❑ <br /> Hardpan E] Adobe El Fill Material.. If yes, type <br /> ................................ <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 . I—-%. <br /> tted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK [ I .- <br /> Size... .............. ...Liquid' Depth.`�/........ <br /> Copocity,./V,0.4- Type...4.............Material... -------No, Compartments...... ..... ...... . <br /> A Distance to nearest: Well.,_- �_7 <br /> LEACHING LINE No. of Lines --------------Foundation_..._/ V --------- ..Prop. Line...../.d.�...... ..... <br /> r of each line.,....1�---�?..............Total Length <br /> _19N..................Length I , , - ................. <br /> 'D, Box�..../....Type Filter Material...1? ..... ... Depth Filter Material-- <br /> Distance to nearest: Well- ...Foundation....._..------------ .....----•-•--. ......_..._........ <br /> Property Line.... ....... <br /> SEEPAGE PIT Depth. ......Diameter....P.-//.-.-,Nu 10) <br /> .... _.Number.....- ------------- - Rock Filled 'Yes No <br /> Water Table Depth............ <br /> .......... -------------Rock Size.... <br /> -11-4- <br /> Distd'nce to nearest: 0I <br /> Line_ ............. <br /> ............ <br /> REPAIR/ADDITION (Prev. Sanitation on Permit#......... <br /> . ........... ........ ....... .......Date........: <br /> Septic Tank (Specify Requirements)............................. <br /> . .......... ........... ................................. ........................ <br /> ................................ <br /> Disposal Field (Specify Requirements).............. <br /> .............................. .......................I....... .......... .................................... ....................... <br /> ........... ------- ........ ......... ......... ............... ........................ ....................................... .................................................. <br /> ............... ................ ...................... .......I—-............I......................•-•--•----.....----......_..--------... <br /> Prow existing and required addition on reverse side).......... -------------------"-------- ---------- ------ <br /> I hereby certify that I have prepared this application and that the,work will be'done'ln accordance with Son Joaquin County <br /> Ordinances, State Laws,"and Rules and Regootio <br /> I .. — . — . - ns of_ Son Joaquin Local Health District. Home owner or licensed agents <br /> Signature certifies-the followi* <br /> ng: <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 Workman's Compensation laws of Calliforni <br /> Signed_ <br /> .............. .......... <br /> .-Owner <br /> BY...........I. ..... <br /> __ _ . .D". ... . - ------ -- ....................Title..._......... <br /> a at ..... ................ ... <br /> t er than owner) <br /> FOR DEPARTMENT USE ONLY zile III <br /> APPLICATION ACCEPTED BY.,.___..__.. � I., Of <br /> ............... .......... ........... ............................ 1,1,,�%�1111_� 1 7 <br /> DIVISION OF LAND NUMBER ..... ......DATE 1 1,151 1 E ...... ..... <br /> ..DATE- <br /> - ----- -- -------------- <br /> ADDITIONAL _.I� W .1 <br /> . .............. <br /> ,CO�AMENTS��NZ-4_ ------- e�� <br /> . ......... <br /> .............. <br /> 4 <br /> .400t <br /> -_ ---- <br /> 1.4.0....... ............................................................ <br /> ......... 41�e, : *.................. */------ <br /> Final Inspiedion by:._........ ------ ----------------- ---------- ----­--------- <br /> EK13 24 ................................. .... .......___Date__ - ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />