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- L FOR OFFICE USE: FOR OFFICE USE: <br /> i <br /> APPLICATION 1OR4_ ANITATION PERMIT <br /> ------------- <br /> (Complete in Triplicate) Permit No._- <br /> ---------------------------- ---- -------------------- <br /> Date Iss <br /> - ued__'-_----_ <br /> -- _----------------------------___-_:..________ This Permit Expires 1 Year From Date Issued <br /> fi <br /> Application is hereby made to the San Joaquin Local Health Disthet�or 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 dndHRe' ulations: <br /> 9117041? <br /> �QQ ------------------ -CENSUS TRACT---- --- - - ------ <br /> JOBADDRESS/LOCATIO ._-- _ - ---- _--- --- --------gip.-F..1.--�-_/-- -- --- ___-- ------- � <br /> Owner's Name : -- - ----- ----- ----- - -- --- --- ------------ Phone <br /> Address--------------- - ----7-' [ - ------------= City--------- ------------------------------------zip- _--------------------------- <br /> Contractor's Nome---- <br /> Installation <br /> ame--- =License # � ..`. Phone ,r-.d <br /> ` Commercial ❑ Trailer Court ❑ <br /> t i M el ❑ Other---'-.----------------------------------------- <br /> --- <br /> - ------ - f <br /> Inst dation will serve: Residence Apartment House Comore - <br /> _ ; k <br /> Number of living units:_..____._-_.___Number of bedrooms.;��-___Garbage Grinder------------Lof Size._-__ :__�.��_ _ __---_.__.- .._ <br /> -- 4 <br /> ---Private. <br /> El <br /> Supply: Public System and name _ ❑ <br /> Character of soil to a depth of 3 feet: - Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan E] Adobe❑ . Fill Material----------- yes, type------- , " `'_. <br /> {Plot plan, showing size of lot, location sof system in relation to wells, buildings,'etc.'must be placed on reverse side.} a <br /> NEW INSTALLATION: ' ' .(No'septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT : SEPTIC TANK-'[t]: Size._=_ _ ___ _ ti ___._ _s_j"'_ ___ _Liquid Depth-.. E_ <br /> Capacity-- - C2z)--:Type- �-----:___---Material---- :--No. Compartments.- ---------- <br /> t <br /> l _ _,.. .Distance•to nearest: Well.z._-=.._:_- _- ��:___Foundation._j� ______________._.__=Prop. Line_____5 ---------------- <br /> LEACHING LINE: [ ] No. of Lines !_._______..Length.of each lin.e.__,----- .dl_______________Total Length..-_/_74-------.-_-______;._'_- <br /> -i i� <br /> 'D' Box---/....--Type Filter Material------ --_ -__ Depth Filter Material--_- - ------ ---------<------°-----.------:'_----------- .,i <br /> Distanc6 to nearest: Well- ------ :-----Foundation----------------------------Property Line.------------------------------�_._. <br /> SEEPAGE PIT De th f7_._-Diameter a _-Number Rock Size'____._ - _________k___= <br /> . Rock Filled Ye N <br /> Water Table Depth =------------------ -- — �- <br /> -- - .----._. _.. <br /> to nearest: Well-----__._ _ ''-_.F.oundation--_$Q .Prop. Line------ --------- <br /> Distance <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--- ___--_:_ ___ '. '__:. :.Date f <br /> Septic Tank (Specify Requirements)--- : ----- --------------------------------------------------- ` ...... <br /> - <br /> ' Pt <br /> - ------------------ <br /> I <br /> Disposal Field (Specify Requirements)-- -.--------:-------- ------------------ --------------------------- - -- - - --- ---------- --------------- <br /> k <br /> ------------- <br /> ----------------------------------- <br /> ------------------ = -----------------------7---- <br /> ----------------------------- ----------------------- ------- = - ' <br /> --- ---------- ---- ----- <br /> . (Draw existing and required addition on reverse sidel '°] s <br /> 1 hereby certify that I hare-prepared,this application and that:the'work will be done in accordak ce with', San Joaquin County <br /> Ordinances,- State. Laws, and Rules and Regulations of the San Joaquin-Local Health District. H me owner or licensed agents <br /> signature certifies the follawing: II . <br /> "I certify that in 'the performance of;the.work for which this 'periiit-ii'lssued, •1 sliall not employ ny person-i`n(-such manner as <br /> to became subject to Workman's. Compensation Jaws .of California." . -. : <br /> SignedOwner <br /> W_� <br /> y� i 3 i <br /> By-1 - --- -- - = 1---'--1:Y -..: --'-Title <br /> ti <br /> € <br /> (If other than:owner) <br /> i t FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ;k------- .y,------:------ ,.---------------- ------"---=---- - --DA <br /> DIVISION OF LAND NUMBER / - := _---------------- ---- -----------.--:`.= = DATE <br /> ADDITIONAL COMME/N�TS.3�_j�- ---- .. - t `*F r -' `` '�C-�t1�' .=`--- <br /> --------- <br /> ------------ <br /> � - � - 77 r 0' ' <br /> _� - ------------------------------- <br /> e <br /> _ °: D ` it � ----------------- <br /> alIns-Inspection G - _FinbY'---=-- -- - - -- - --- ----------- ---------------- <br /> - <br /> EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> p <br />