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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> {Complete in Triplicate) Permit <br /> ------------------------------------------------- ----- ' ) <br /> Date Issued_____.._ _---- <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local{Healthi District'for pe mit 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..-/04WA' <br /> p <br /> . (' � �Owner's Name--Z ---- --- ------- <br /> -- <br /> Address / -C. Citzip .2-6�a4 ----------------------- ---- ---- :5�-- <br /> / <br /> Contractor's Name --- Gr.1-- ---------------------------License #_3o`S-T2�----Phone- <br /> Installation will serve: Residence W�– Apartment House.❑ Commercial ❑ Trailer Court ❑ y <br /> Motel ❑ Other------------------------ �.: <br /> l <br /> Number of living units------ -------Number of bedrooms--- _-_Garbage Grinde_r_.A_-Lot Size___--f-lQc+ ---------------- -----_ <br /> Water Supply. Public System and name---------------------------------- ------------------------------------------------- ----------------- ='" Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy_Loam lay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material--------_---If Yes;type----..-____r__----------------- <br /> [Plot plan, showing size of lot,location of system,in-reiafion-ho wells, buildings, etc. must be placed on reverse side.] <br /> NEW INSTALLATION: (No septic,.tank or seepage pitepermitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ] SEPTIC 7ANIC ,[Zj � Size:�,_------ - -- ------ �-------�--------_-_--- -_Liquid Depth--------._----------------- <br /> Capacity Type " '- `--------..-Material No. Compartments <br /> Distance�td nearest: Well.. --------------------•-------------_---Foundation:-=-- :.,, �.W.- -.,Prop.-Line=-. ..------------------'r <br /> LEACHING LINE [ ] No. of -------- Length of`each ------------------Total Lenth.__-_____________--_------_---- <br /> 'D' Box_---------Type Filter Material--------------------Depth Filter Materiai:7--7 --°_---.- <br /> 7 <br /> -� o44-----_____ __ ----Property Line nearest: Well--------------- :- -� Fdti ---------- <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No❑ <br /> Water Table Depth -------------------------- -----------------------------Rock Size----- ---` '-------- <br /> - . -------- <br /> REPAIR/ADDITION <br /> ' - ---------- <br /> --L--i-n--e--.-=-`-------- <br /> dation-� _ _- Prop.Distance to`nearest:"Well --------- ---- ---------- -----=-Foun - "- - <br /> REPAIR/ADDITION ------------------ <br /> Septic <br /> ' --_ -�--� <br /> (Prev. Sanitation Permit#---------------------------------------------------Date--- --=-:----------------- ------------------ <br /> Septic Tank (Specify Requirements)----------------- --- ------------------------------------------------- ------------------------------------------------ <br /> Disposa! Field (Specify R//equirements) �®1---- ---------�---- ---------r���r--=�-'���w!'------------------- <br /> -41 <br /> ------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw <br /> ----------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 San Joaquin Local Health District, Home owner or licensed agents <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 as <br /> to become subject Work an's Compensation laws of California." <br /> Signed---------- ---- - --- -- ---- ------------------------------------------------------Owner M & C. SEPTIC TANK SI=R. <br /> . P. 0. Box 94 <br /> BY---- t ---- ------- ------------------- ------------ -----------------Titlel4lt_ ----------- -ACar DO;-Caiif. 95220 <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY >w = ------ --------------------------------------- ------ DATE 3 <br /> DIVISIONOF LAND NUMBER ------------------- ---------------------- --------------- ---------- ------------------DATE--- ------------------------- ------------------ <br /> ADDITIONALCOMMENTS-------- ----- ------------------------------------------------- ----------------------------- --------- --------------------- ------------- ------- ------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------- -------------------- ----------------------- <br /> -------------------------------- j ------------------------------------------------------------------- ------------ --- ------------- <br /> FinalInspection by �3'------- -----------------------------------:-------------------------------------Date".�'--Z� .. --------------------- <br /> M 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT MS 21677 REV. 7/76 sen <br />