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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 1 AG <br /> .................................. .. .. ............. <br /> Permit No.. .�j_...3. <br /> (Complete in Triplicate) <br /> Date Issued........ ' <br /> ................................ ... ..._.._..._ This Permit Expires 1 Year From Date Issued s <br /> Application is hereby made to-the Son 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 /> Z5 y <br /> JOS ADDRESS/LOC TlON_.. .."7_ ._ ...---. Ne . . _...1��L r.................a--------------------..CENSUS TRACT---------------....._.._...-.-- <br /> Owner's Name ._ . <br /> �d�101Y5�,_.... .... .. "= Rhone ................... <br /> Address... ..__................. <br /> .Q. City...6. WlC- ! .._.. zip----.................. rte... <br /> Contractor's Namet�C.1. +z''�----II��-c. yZ.E <br /> ti License #--1 .Phane- �.. :" r./ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Otherr.. : ....... ......... ..i <br /> Number of living units:..... l_........Number of bedrooms....�.Garbage Grin der."......Lot Size................ ... ---------- <br /> f <br /> Water Supply: Public System and name _ 11 .E. Private <br /> ---..................... .:..._...._... ...... <br /> ....._..--- ...... <br /> Character of soil to a depth of.3 feet: Sand ❑ Silt❑ Clay ❑ Peatf❑ Sandy loam [] Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material.. ... . . if yes, type.__.....E_: _.... <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must beplaced on reverse side.] <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted-if pdblic mower is�'ivaila$le within 200•feet,i <br /> PACKAGE TREATMENT '` � <br /> ] SEPTIC TANK [ j ,Size ....41�.-��I�.-�..............:.._ . - .Liquid Deptli.....',j..... ....'.......... <br /> Capacity-1 .......Typ -� aferial- +��e�_No► Compartments------ <br /> ................. <br /> f f <br /> 'Distance to nearest: Well-------- <br /> �Q...............:.:......Foundation.,.:;__la.__...__._..Prop. Line_jQ......... <br /> LEACHING LINE [ ] No. of Lines ._.__ ...... ..... - Length of•each� re�..=G� _.- . -- Total Length <br /> � / <br /> .............. <br /> i � iMr <Depsh Filter M ral.-.-_---- ......._ .. .._.D' Box... Type Filter Material _ nn <br /> .... <br /> 20 <br /> Distance to Barest: Well__. -- Foundation.___. .................Property Line..._. ._......_-_.._.� <br /> SEEPAGE PIT ( ] Depth.C26....._Diameter---,.c` . . i- Number r...................... .......... Rock Filled Yes ❑ No <br /> Water Table Depth-----------�cl®.......�. Rock Slie . �`�' j <br /> Distance to nearest: Well....- ®d......___..............Foundation.-_..f O.p........Prop. Line-.L.4e.0-....._.. .. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.......................... ...............Date;..........r:-°.._....-.... ............ <br /> ..-.•-) <br /> Septic Tank {Specify Requirements} ..........................................------------------ _. ......... <br /> Disposal Field (Specify Requirements)_ .._ ........... ...................................... ............_.--............._._..--_-._-- <br /> --------------------------------- ---------------------•----------------...------------------........ ..---------... ... .. ---.-----.._-- -- <br /> ----------•----- - ----- ----------:----- -------------- ------ ... ..--------- -------- ..... <br /> (Draw existing and required addition on reverse side] <br /> I hereby certify that I have prepared this application and that the work wiil�be done in accordance with San Joaquin Count) <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 <br /> ollowing:"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 California." <br /> Signed ---- --- --. -. . .Owner <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ... `.�. DATE ...�"/x':.Z.S'........................ <br /> DIVISION OF LAND NUMBER - _...... --.- ATE............................ .. ................ <br /> ADDITIONAL COMMENTS-...--_- - Q.��-cam..--------` r'. Q../� !`7_....-._ 3 .7_ __.. 1C.._...-•--------- <br /> V ._ r <br /> ..---•............................................................•- ... .................... ----------:-.----------- .................................... ........... . ....-- .._..-.... ..... <br /> •--- ----------------------- .............. <br /> ---------------------------....................__... .. - ._..-__-..... ..._J ..._-..._-.-._...---.-.--_-.._- <br /> , _ .. ------------__•____ _ _ _ ._.._---- <br /> Final Inspection by:................. .. ­ <br /> ----------------f...---------...---- - - --....------------. Date.. G• g.... <br /> EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3A <br />