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i FOR OFFICE USE: FOR OFFICE USE: <br /> a APPLICATION FCR-SANITATION PERMIT <br /> (Complete in Triplicate) Permit No,?.._-�}_ .__ ' <br /> ---------- ............................ ------ k <br /> Date Issued.`a.`' ,• <br /> ......••... ........................ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> This application is.made in compliance with County Ordinance No. 541.and existing Rules and Regufl tions: <br /> 1 �-- TRACT 1....._.. <br />! JOB ADDRESS/LOCATION.. C...... .. <br /> .. ..L r �_vr� CENSUS- .----....."....I <br /> Owner's Name._.. ..._i`T P 'L Cly r� <br /> ................... -------------- ----------------Phone.--- --- ..... - <br /> Address -- -----city <br /> Contractor's Name ._C G� --......License # ...... ----- Phone.... ------ --- ----- <br /> ❑ ❑ ❑ <br /> Installation will serve: Residence artment House Commercial Trailer Court <br /> Motel ❑ Other- .. <br /> Number of living units:_.--- ----------Number of bedrooms... T Garbage Grinder............Lot Size.........::.: d .......,. , <br /> - <br /> v <br /> t <br /> Water Supply: Public System and name'_ .: Priv <br /> --------------------- <br /> Character <br /> ----- --Character of soil to a depth of 3 feet: .Sand ❑ Silt(] Clay ❑ Peat ❑ Sandy Loam ❑ C1_ay-lan.m <br /> Hardpan ❑ Adobe Fill Material . .... ....If es, type-- 'rte -- <br /> ❑ y <br /> {Plot plan, showing siie of lot, locationiof system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No -septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE-TREATMENT [ ] SEPTIC TANK [r.]' Size . ................. <br /> . ..l.. . <br /> .............................._Liquid Depth.. <br /> ..:.-.........:-------._-0 <br /> 6�vCapacity `'U------TYpe� .� Material. � .. -To—Comariments_....... ............ <br /> lstance to nearest: Well-....". ------ -------- ------ Foundation...10. ............Prop. Line y. .ye�-:--- <br /> LEACHING LINE i�3 " 'V <br /> [ Na. of Lines.. ---.Length of each line:- 1�.:-- :----..... Total Length- <br /> D' <br /> ength-.. <br /> 'D' Box. _ � �� -2� i� . .. <br /> -.Type Filter Material-3A--.-- .Depth Filter Material...----..1%--------------:------------.------ ---...... <br /> [ 6Uf. 1_. <br /> Distance to nearest: Well., ...........Foundations -....._.Property LineZ .n4.,..L�� ........... <br /> SEEPAGE PIT [ Depth.. ._�.. _Diameter.._ ...Number 3-------------------- Rock Filled Yes Ems— o ❑ �J <br /> Water Table Depth.------------------------------ --- -- ------------- ---Rock Size.- . -----............... ----- - - <br /> A <br /> ,o� <br /> Distance to nearest: Well..-.. "[pc?.___...-.... -------Foundation_ .._.. Pro Line_ <br /> REPAIR/ADDITION (Prev. Sanitation Peirmit#.................................. ._....... - --- <br /> -------- -- -----^-- <br /> ) <br /> Septic Tank (Specify Requirements)-------i.;... ------------------------- ' ......... <br /> Disposal Field (Specify Requirements[......=---------------- ------ ----------- --- ----L---- - <br /> ----- ---•-"----------------- -- ---------------------••-----• ----- - ---.................................. --...------. -------- <br /> --- ------- -- ------------------------------.... ------------------• --------- -----------I------------•---•------------------------ .-­------------ ----------------................ .. <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ' <br /> Ordinances, State taws, and Rules and 'Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: J <br /> "1 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." t <br /> Signed.-- -- - -------- ----Owner <br /> . <br /> By.....". .. I. - _POU.......�.ahe.. ----- .....Title----------------------- <br /> � (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...-- DATE ...... _- �."7 ._.. <br /> --------------------------- ---------------- ........ ------- <br /> DIVISIONOF LAND NUMBER--- ----------------- ---- -------------- ------- ----------- -- --- -------- DATE---- ----- ----- ..........--------------- <br /> ADDITIONAL <br /> -- -------.._.ADDITIONAL COMMENTS. ------- - <br /> ----------- <br /> ---------------------------- ----- . <br /> At— ell <br /> ----------- ------ -------------- <br /> Y <br /> �' - -------- - - <br /> Final-lnspectlon by: ----- ------ ---------- ---............Date <br /> '... .. .Y. <br /> EH 13 24 - 1 <br /> SA JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />