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FQR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------- <br /> ...... <br /> (Complete in Triplicate) Permit No. ... ... <br /> ...............:----------- ...... ...... .... .......... <br /> Date Issued_6_/-7-.;74!5� <br /> ....... <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 Ordina,nce No. 549 and existing Rules and Regulations: <br /> TI N . . <br /> JOB ADDRESS/LOCZATION.... . ...CENSUS TRACT----------------- ........ <br /> --------- -- <br /> Owner's Name.._... .. . .... ... ... <br /> --- ----------------- . .................Phone-------------------------- ............ <br /> Address-.:--- _ -------- ..... ..... Cit . ... .........I.......L...........zip------ ...... ......... <br /> Contractor's ~..,..License <br /> Installation will serve: Residence E] Apartment House E] Commercial Trailer Court F-l <br /> Motel M Other. ..................... <br /> Number of living units: __6,;1_..'_Number of bedroom Go rbag e Grinclesr._-(j�F_Lot Size----//A( <br /> Wate(' Supply: Public System and name ...... ----------- ----------------------------------------- ------..._. .Private <br /> Character of soil to a depth of 3'feet: Sand El Silt 0 Clay 0 Peat E] Sandy Loam E] Clay Loam <br /> Hardpan E] Adobe Fill Material.. .If yes, type__- ._..-._.._.-... <br /> (plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be place'd on reverse side.) <br /> NEWINSTALLAVON: (No septic tank or seepage'pit permitted if public sewer is available within 200 feet,) <br /> PACKAGETREK-IM t N f <br /> - .-No-. Compariments-.---cp------- ................. <br /> Distance to nearest: Well.,'/00.......... ..................Foundation...ZO, ...-....Prop. Line---- .......... <br /> LEACHING LINE Dhr No. of Lines ....._/...........--..Length of each lino _�.67------- To_t_j1_T_e_�_gthr--. -------- --- <br /> D' Box.... _ Type Filter Material../VO <br /> ��..,,.Depth filter Material_ 4. ------------ .................... <br /> Distance to nearest: Well.../0_0_../...­­ Foundation.-../O...""*-'......,..Property Lfn�6___4 --------------- <br /> SEEPAGE <br /> ----- ----SEEPAGE PIT �Filled YesA No <br /> Depth-,9.,S"7_"..Diameter----!!7---_......Number_- /---------------------- Rock k' <br /> Water Table Depth.--.-----5;lpl-------- ............ ----------------- --Rock Size._.02- - ---- ----- --- ----------------- <br /> Distance to nearest: Well------ ............Foundation--- Line........4b ... ... <br /> REPAlk/ADDITION (Prev. Sanitation Permit#................................... .. .........-.Date---.- -- ----- ------ -------------- <br /> Septic Tank (Specify Requirements).--------------­-------- <br /> ...................... ..................... ----------------------- ....... <br /> Disposal Field (Specify Requirements)__ ............... -------- ---------------­---------- --------- <br /> ................................ <br /> --------------------- ------------------ ------ ............ ---- ------ <br /> • -------------------- ------- ......... -------- <br /> ------------------- ------------- - -----­­- ---------------------------------------- .........1—-------------- --------------- ....... . .. .... <br /> lDrow existing and required addition on reverse side) �0 , <br /> thereby certify that I have prepared this application and that the work will be done in accordance wifh Son Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the.-*San-Joaq.uin,Local.-He*]th 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 noi—e`mploy­ar;y_p.-eir's-o-Win 'such manner as <br /> to become -subject to Workman's Compensation laws of California." <br /> Signed.......... ---------------- CU�RENCE`S SEPTIC StWER -SERVICE <br /> 5111 k 263 So. Oro <br /> By------- ......... .... S,,Ockto Calif. 95205_ <br /> ......Title.— - ----------------- .. . ....r)........ <br /> P.h-4�3�-3 2 0 9 "-Con i Y I Tra UUT U F 2-6 7 T 7 <br /> K <br /> (If other'than owner) -3. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- ....... .. ----- ----- ­------------.._. ... .DATE _b-A-3. 79 ........... <br /> DIVISION OF LAND NUMBER '.- -------------- ---------_----- --------.....DATE------_-------- <br /> ........... ---------------- ----- ---------- <br /> ADDITIONAL COMMENTS...... -----'--- ------- ­-- - - <br /> -----------­........ .................. ...... . .............I------ --- ---- ------------------- ............... ..................... <br /> ............ ....... ------ -­ <br /> ' .....-.--.-..----- .................-..--.-.-.-.--.-.-.-.-.-.-.-.-.-.--.-.-I-—­..­. ­...­...-.--.-.--.-.--.-.-.-.-.­. ---- --- -.-.-.-....­­ ­. ---; <br /> Final lnspe6ionby: <br /> - <br /> ---- ...-. <br /> - .............. ............................. ------ ... --.--- <br /> EH 13 24SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />