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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATSON FOR SANITATION PERMIT <br /> ------------------------------._.._..... -----.-... -- Permit No..,7g_..7�� <br /> (Complete in Triplicate) <br /> ---------------------------- -------=---- <br /> - -------- Date Issued--.�-f�.:.�� <br /> ..•...................................................... This Permit Expires 1 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 /> •CENSUS TRACT............... --.......--- <br /> JOB ADDRESS/LO T N..... ..�J.._._ .�P....... ---- <br /> Owner's Name ..... ----- Phone --..---- <br /> Address---.r/07....' ..�_.. ..... .. ------ ......... . .......City ZiP .. /... <br /> Contractor's Name-..--. > @'� .. ....... . ... ...License # -1` `�p Phone.'y ------------------ ----- <br /> Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court [I <br /> Motel ❑ Other.... ....... ----------------- <br /> Number of living units:....,..-.--Number of bedrooms.: arb/ag� Grinder..._....---Lot Size.-- ±( .--•---..---. <br /> Water Supply. Public System and name..... W ----------- --------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe)< Fill Material.. .... ....if yes, type--------------------------- - <br /> (Plot plan, showing size of lot, location of 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 <br /> 20fe ) <br /> � Z . ! Liquid Depth, <br /> __!0/._. <br /> PACKAGE TREATMENT SEPTIC TANK Size <br /> Copacity./ROO.....TyPEP4. -Matarial_�. ...No. -- <br /> a <br /> Compartments....-.:A.-r. <br /> Distance to nearest: Well...... - - _----------------Foundation,lb-_ . - Prop. Line_-_ ...- _ ...-........ <br /> r ..l <br /> LEACHING LINE [L)/No, of Lines .... .. <br /> ----------------- Length of each line $S.te./--...g- -..:... Total LLe}}ngth . �-��- <br /> Depth Filter Material..... d ..._...--- e-----------. <br /> D' Box--. Type Filter Material.�?+. <br /> --. <br /> g�h7 <br /> cto nea� �-jst: Well.. _.....Foundation... -.f--------.-.Property Line.-.. --r-.� y -------..SEEPAGE PIT [I - ,' Diameter-..3.3.- --..Number__...---o ------------------- it R�k Fillers Yes No ❑ <br /> Water Table Depth----�-�10---------------------------------------Rock Size.- ..0 �------- ... o • <br /> Distance to nearest: Well------ A <br /> � ....----._Foundation-.-. .... - ----.Prop. Line.... ......... - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------- ------------ - .............Date--------...............-----------------------) <br /> Septic Tank (Specify Requirements)... ---------------------------- ----------- ------- --------- ----- -• <br /> Disposal Field (Specify Requirements)---....... ...........................=------------------------------------- -- ­_...... --------- <br /> ------------------------- . <br /> -----------•---•----------------. ----- .......................................... -------...------- ------------ ----------------------------------------- .. .................... .......... <br /> ------------------------------------------------------------ ----------------- ---------- <br /> {brow existing and required addition on reverse side) <br /> I hereby certify that I 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 beco uWect to Wo kmon' Compensation laws of California." <br /> Signed..--. - t Owner <br /> �/ /,- <br /> $Y ------ -------- ----- -- `' r -- ------ f Title..... . <br /> {If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.......-.- DATE....J�- /-:_�.r.�----- --------- <br /> DIVISION OF LAND NUMBER .. ... ................ . ...........DATE...............- -...------- -- --------- <br /> ADDITIONAL COMMENTS....----- --- ------------------------------ .................. - ------....-- ---------- <br /> -- ---- <br /> $Date._. . __....Final Inspetton by:. <br /> 68 <br /> 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&5 21677 REV. 7/76 3M <br /> f <br />