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FOR.OFFICE USE; FOR OFFICE USE: % <br /> ----------- ------- APPLICATION FOR SANITATION PERMIT Permit No..775f <br /> (Complete In Triplicate) <br /> --­--------­-- ............. <br /> --------­------d- Date Issued,J'---/-7,P <br /> ........ ------._ 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/LOCATION. ------------------------------- .-,-.CENSUS TRACT-.----------..------ ......... <br /> Owner's Name.. -- ------ .....__..._-------------------•........... -------.-Phone----------------- .............. <br /> Address.........., <br /> ............. City......... ...... <br /> Phone:.Contractor's Name......... -------------- <br /> Installation will serve: e�is,dence [3- Apartment,House —1- Commercial C] Trailer Court.7 <br /> Mo'tel F-1 Other...... ......................I............. <br /> Number of living units:...... -NumbiEir of bedrooms -.,....Garbage Grinder ..._.....Lot Size------- <br /> Water Supply: Public System;and name-..................... ...... --------------- ------------------------------------------------ ......-------.Private 0 <br /> 00racter of soif to a depth of 3 feet, Sand.[) Silt❑ Clay L7 Peat[] Sandy Loam El Clay Loam [D <br /> Hardpain Adobe 0 Fill yes,type_.-.. _.­:........ <br /> (Plot plan, show-Ing size of lot, location of system in relation to wells,buildings,.etc.must be placed on reverse side.) <br /> NEW INSTALLATION:- (N6 septic tank or seepdge it <br /> p" ' * mitied"ifpublic sewer is available within 200 feet,) <br /> pit <br /> PACKAGE TREATMENT I SEPTIC TANK FI Size'-.---­.-....­'. --.LiqCjid Depth..__.__.;... -------- <br /> Capacity............... ----Type ­:-­----- ---..'­A4at&riaI....*-.­*.................No:Compartments----------- ---------------- <br /> X <br /> Distance to riecirest.Well...--_:_ .............. Prop. Line_,.- : --e. Lo. <br /> LEACHING LINE,_ J .) No. of.Lines-.--,....... .......Length.of.each line-.*---------­-------- total:jength.­-.,. --- ------------------------ <br /> 'D' Box.-:...­...Type Filter Material....................Depth Filter Material-.... -------------------------- ........I--------- <br /> Distcrice,to nea4st. Well................ ....Founclation-­,:------- ------ -.-,.--Prop" Line------ ---------------- ......... <br /> Dep -,--,,.-Diameter -------------------Numb,%r­­----' ............. Rock Filled -Yes No <br /> SEEPAGE PIT th -------- ❑ <br /> - <br /> Water Table Depth-'; ................................. Rock Size------------- -------------------------- <br /> 4 <br /> ---------------­­ <br /> Diston6eld'nedrdst: Well_..._.___`..--...._._..........*............Youndation..-*----- -----------.-".Prop. Line* <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-!....-...... <br /> ................... .......... ........... <br /> Septic Tank:iSpecify Requirements)------t-.... <br /> ............ --­-----------­------ <br /> Disposal Field (Specify Requirements)- <br /> ............. --------------- ....................................... --------------------------------- ----------*--------- ..........--------:­­....... ............................. <br /> .................. ---------­­­.......... ........ ........... ........................­.­............................ ........ ...._.I................... . . <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify thotl ho've prepared"this application-and that the I work will-be done In accordance with Son Joaquin- County <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed,agents <br /> iiis Anture certifies the followin, <br /> 9 <br /> "I certify that in the iperformance of the work for which this permit-li issued, I shall-not employ any person in such manner as <br /> to become subject to Workman's-Compensation laws. of California.". <br /> Signed ----- ----Owner <br /> By!- ........Title�......... ................ ...... -------­------------------ <br /> ------------------�7 <br /> (If other than owner[ F... <br /> FOR DEPARTMENT USE ONLY OE <br /> APPLICATION ACCEPTED BY__._._..__: . ......:­­:....... ---------------- <br /> DIVISION OF LAND NUMBER- --- -- ----------------- -------------­ ............... -------------t-.-,--.-,--, ................ <br /> ................... <br /> ADDITIONAL COMMENTS. ................... ............. ..... ....... -1---- - -- --------I......... <br /> ..........--------- ------- ----------------------------------------------------------------- ---------------•--•---•---------- I -------------------------------------------------------- <br /> .......... ...........I....... ....................I......­­................. ................................. --- - -- ----------- ------I--------------------------------- <br /> -------­---W----------- <br /> 0--------------------.......------------------------­­.....................•----------------------------------- <br /> final-Inspection by.-­­:!T�-------n- �...... ­------------ <br /> -----Date. <br /> ice <br /> EH 1$ 24 UN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV,7/76 3M <br />