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FORQFLUSE: <br /> " t APPLICATION FOR SANITATION PERMITFOR OFFICE USE: <br /> --------------------- ---------------- 7& -tel <br /> (Complete in Triplicate) Permit No_______________________ <br /> ------------------------ -------------------------------- Dn <br /> .: - <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued 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 ADQRESS/LOCATION <br /> --- � ®----- - -- ----- - --------------- -------------------- TRACT--------.-------- <br /> r <br /> i <br /> Owner's Name-------------- - -�--�--- - --- - -_ -----�--------=- --------- --------------=--------- ------ ---- ----Phone --- ------------------------------- <br /> , ' <br /> Address---- -------=------ ' --Cit ----Zi <br /> Contractor's Name--`------__-_= 1-- .. v License #--- �Z1 Phone------------------------------- -- <br /> - - - - <br /> Installation:will.serve: r Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> 4 _.._:...Motel ❑ Other-------- ==-=-------==----=-- - <br /> Number of living units_________ -----Number,of.bedrooms-_1�__-__Garbage Grinder_--;._ --- Lot Size-- _-- ----.__.___...__ ... <br /> Water Supply: Public System and,name___._. .. = _ _ Private E] <br /> Character of soil to a depth cf 3 feet.%Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam❑ –� <br /> T s Hardpan "`Adobe ❑ Fill Materigl'_7-77If yes, type ' <br /> ----- - -- - <br /> [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed'o'n reverse side.) <br /> NEW INSTALLATION: (No septic'tank'or seep ge 'pit permitted if public sewer is available wi#hin 200 feet,] ! <br /> PACKAGE TREATMENT t[ 1 SEPTIC TANK ' [l Size _ X/ ,� __________________Liquid Depth._ (4 <br /> - - ---- . -------------------- <br /> 1Capacity_ -.----_Type-_- .-- 0- --- rMaterial---- �lX ---No. Compartments-- -.-_-__-- �1 <br /> I / Distance,to nearest: Well_ _________.�� ----------- ---Foundation_ .^_______Prop. Line_ <br /> LEA€CHING LINE [6i/} No. ofxLines._____ _;1..___ ----- --- Length of each-line.__,---�__ ----------Total Length.,a-� '---------------+__� <br /> D' Box._:/1._-._T p e Filter Material_-_ ___ Depth Filter Material__-_ '� <br /> --------------------------- <br /> ' <br /> Distance,to nearest: Well__ Property Line-_ ----------------- <br /> SEEPAGE <br /> _ -------__ <br /> � ,` /`� ;--:.:;Foundation= -��/��-- - p Y --- <br /> SEEPAGE PIT [ Depth_ Diameter. h" --Number _.:__ Rock Filled Yes No ❑ <br /> . ...b_ i�;'l. 21--.- _ �/� �`'1%flock Size----/ - �i ---------' ---- <br /> Water Tab]e,Depth.._ ��- <br /> i : ' . f <br /> 4 Distance to nearest:Well-------- Prop. Line__.__ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_'---------------------------- ---_..Date- --------- ) <br /> - .------.-- <br /> Septic Tank (Specify Requirements) '... ----- --- - R <br /> Disposal Field (Specify Requirements): ------ ----------------------------------------------------- -- -------------------------------------------- ----------------- <br /> --------------------------- -----------------~ ---- !� <br /> (Draw existing and required addition on reverse side) ,x` <br /> I hereby certify that l have prepared this application and-that the work will be -doneJn 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: ; � Y <br /> "I certify that in the performbrice"of the work for which this permit is:isedT'su�, I t employ any 'person in such manner <br /> to become subject to..Wo man's Compensation laws of California,;' `s yt -#rr 4 f <br /> Signed--------=------ ---- - -=-- ---------Owner <br /> BY---- --- ---- - Title.- - <br /> - - <br /> (If other than owner) <br /> x FOR DEPARTMENT USE ONLY` 1 <br /> APPLICATION ACCEPTED BY- --------- -------------------- '------=---DATE <br /> DIVISION OF LAND NUMBER-- ------------ -------------- ---- ------------------------------------------------------ ---------.DATE------- ------ <br /> ADDITIONAL COMMENTS -------------- ------- ---- = <br /> —� — - v . <br /> ----------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- ------ -. <br /> Final Inspection•by:::..- _ ------------� - - Date: �/ ....1 <br /> -_- - <br /> EH 13 24 SAN JO/QUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br /> E <br />