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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- ......... .................. --------- <br /> (Compleie in-Tri-P I I tote) Permit <br /> Date,ls <br /> sued. <br /> .................... ....................... This Permit Expires I Year From Date Issued % y3 <br /> Application is hereby made to.the San J I oaquin 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 Regulationsz <br /> JOB ADDRESS/LOCATION................7,q/-f- Z`Xr 0-50. sI` <br /> ---------------------- ......I...... ------------------- .....CENSUS TRACT--.-- .......... <br /> Owner's Name.... �ra � ... ....... . ...... ........ ------ ----------------Phone...-----------....------..---... <br /> Address .. ... ------ j City- - -- - V <br /> --- ------- <br /> - <br /> -- zip------------------- <br /> Contractor's Name....... <br /> ........ ...................... ------ ......License /.+5....SSGPhone._S, ---------------------_--- <br /> Installation will serve: L rtResidence Apartment House E] Commercial E] Trailer Court ❑ <br /> Z"'Motel 'F❑ Other--.. -- - ------ ------ ------- <br /> Number of living units: J__,__.:�.Numbe'r of I bedrooms.-.A _Garbag.e Grinder-------- ...Lot Size....... <br /> ....... .... .. <br /> Water Supply: Public System and name'+ ........ ....... ------------------_.:............ ........... -------- - --- -----------------Private <br /> Character of soil to a depth of 3 feet: <br /> ,Sand E] Silt [D Clay ❑ Peat ❑ Sandy Loam E] Clay Loom E] <br /> Hardpan Adobe E] Fill Waterial ....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 permit'ted,if public sewer is'—available within 200 feet,} <br /> PACKAGE TREATMENT SEPTIC TANK Size................::.....-------.-----:-..`---.-------..---Liquid Depth.'-.."-- ------- <br /> Capacity. .......Type.-' C.9'...Mate-rial_--------------r.........No. Compartments....... ........................ <br /> Distance to nearest: Well_---- -- ---- ..................Foundation............ .............Prop. Line---f�F.................. <br /> i---------------_------_ .., �s, 0 <br /> LEACHING LINE No. of Lines Length-of each,I ine . ............ Total Length ....1.1�5............................. <br /> 'D' Box_ J, Type Filter Material..! Bch <br /> Depth Filter Materials_.._o------------------------------------- ---- <br /> Distance,to nearest: Well----... ......__Founclation...../6------------- Property Line.....-..--------- ....... <br /> SEEPAGE PIT Depth........ . ....iDiameter....................Number-_---------------------------- Rock Filled Yes <br /> Water Table Depth------------------------------- -__........---.. ......Rock Size_......... <br /> .................. <br /> Distance to nearI esti Well.................................... -------Foundation.... ......Prop. Line.-...-.-.-.------..----... <br /> ........................ ...............Date------------ - _REPAIR/ADDITION (Prev, Sanitation Permit#..........• _ <br /> Septic Tank (Spe6fy Re'q4uireients)._ ----------------------------------------­------------- ...... <br /> ------------- ............... <br /> • <br /> DisposalField (Specify Requirements).- ........ ........ ............. ------I--------------------­----­-------------- ----------------- ................................. <br /> ­ - --------------_----------- -------- <br /> ------------------------ -------------------------- --------------------------- ------------------------------------------ -------------_----- ------------­----------------- ------------ <br /> Praw existing and required addition on reverse side) <br /> I hereby rectify-fhbit 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 Son Joaquin Local Health District. Home'owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of theI 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.....E /4*//- > <br /> .. ...... �e__y--------------- -- ------ ------- - ------ ...Owner <br /> By------- ------- ...... -------------­ Title----------------------- -------------- ----------- ........ <br /> Of O'Ker-than owner) <br /> 9)�DEPAR7MENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED B ..........-DATE Y------- --- ---------- -- - ------------------- <br /> DIVISION OF LAND NUMBER.'.................. ......--__---._:...............---------..DATE_...... ------------- <br /> ----------------- <br /> ADDITIONALCOMMENTS ­ ---------- ---------------------------------I................ ............... ---------_ ------------------- --------------- .................... <br /> ------­--------------r----------------------- ..................­­------------ --------------------------------­---------------- __­­... .............. <br /> ------- - - - --- -- ----- --------- <br /> ............. .............. ------ ........­�I : — . . I ­­.................. .............. ­­ <br /> ..... . .......... ............. . ....... ......... ---------------------- -------------- <br /> ------•---------- ------------ --------------------- ---- - V------ --- ------ ---------- ----- <br /> -------------------- --- <br /> Final-Inspection by...-------- --- . ..... . ... --- ---- --- Date ......� <br /> ---------------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />