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y =� FOR OFFICE USE: 4 <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> r t ------------- ------------------- ----- (Complete in Triplicate) <br /> l <br /> ------ -------- -------- Date Issued.�.-- _- --- <br /> .,_. <br /> This Permit Expires 1 Year From Date Issued <br /> 0k7 rein described. <br /> 4 Application is hereby made to tl•le S Joaquin Local Health District for a per-m.it to construct and,install thew rk he <br /> This a plication is made in compliance with County Ordinance No5Q9�and�-exions <br /> sting Rules and Regulate <br /> �'`{j° <br /> k _ <br /> � <br /> C <br /> -�•�-L•icense-#�a_ : <br /> or <br /> tie---- <br /> Phone- - --��=-CENUSTRA <br /> _ XJOB ADDRESS/LOCA7lON " 1 <br /> OwnersNme.�- -- --- -----.-j;Addr �"_=��'7_Ph -- <br /> ' <br /> ------------- <br /> Ci <br /> kkk Contractor's Name_.'_.__.__.__ --- <br /> s _ ..-r .y. . _ ... } . <br /> lnstallation�wi'Flserve: Residence ❑ Apartment House.❑ rCommer i I Trailer Court ❑ <br /> Motel•❑ t r-- .t.R <br /> .S� <br /> Number of living units: Number.of bedrooms'._---- .--Garbcige_Grindela_.____.._____Lot;Size.-.,--.-----. -� 3 <br /> i -Private ❑ <br /> Water Supply: Public Syst� and name -. w--- '--- --- s -- --- \ <br /> Silt 'Cloy <br /> Sandy Loamr❑ Clay Loam 0 <br /> Ch iracter of"soil to a depth of 3 feet: Sand ❑ ❑ _ Y ❑ <br /> ` Hardpan ❑ ;� Adobe Fill Material_ , type --F ;� ` <br /> i 1 <br /> f (Plot plan, -wells, buildings, etc. mus <br /> showing size of lot, location of system in relation to <br /> t be placed�`on reverse side.} <br /> NEW INSTALLATION: '"(No.�septic tank or seepage pit permitted if pudic sewer is available within 200 feet,) <br /> G .., i. -- -=-----._Liquid Depth.------ ---- -------------- <br /> SEP <br /> ------ -- <br /> SEPTIC TANK [_] Size_ --------- - <br /> PACKAGE TREATMENT 11" ' q <br /> i , . - . = Maternal r ,... ? $,N o ,Compartments <br /> ---- -------=apacitY-'- --- - - TYPe ; <br /> epii <br /> a + 2 e <br /> Distance'to nearest: Well------- --------------- <br /> .. <br /> - -_ Foun n_. ._. Prop <br /> datio t <br /> Na. of Lines.___ ------ <br /> - .Length_of each line),., -- }---. 7o al; Length-- <br /> . -- . <br /> LEACHING LINE' ['.]. <br /> i D' 8ox.._ • .Type Filter Material ----------- Depth Filter Material- <br /> y. <br /> ` Distaneeito nearest: Foundation --------------------------Property Li <br /> _.._pt.:•. ..... k �,.� Rock Filled .Yes <br /> SEEPAGE PIT ❑ No <br /> i :--- Diameter. <br /> Number Rock <br /> Deh .-_. - -- - ._ +. <br /> # a Water Table Dept h---=------- --------- --------- ---- Si e <br /> Distance to nearest: Well: i ` E6unda#ion---- ---- -------- = Prop. Line_ <br /> # ; I <br /> i <br /> I---------------- <br /> REPAIR/ADDITION (Preva Sanitation Permit#---.-- --,---=---:---- } <br /> i <br /> Septic Tank (Specify Requirements)_'----------------------------' = - ,s <br /> I - ---------------- ----- --------- �! ------- --- <br /> Dis'posa <br /> --- <br /> Dis`posal Field (Specify Requirements)--- --------- - -- <br /> --- - ------=---------- <br /> --------------------- <br /> ----- ------ <br /> - <br /> �' - ---------- ---- -------- ---------- <br /> 3 .. = -- '--- -------- -------- ----- -----------=--- <br /> ---- ; . } <br /> ± ; " (Draw existing and required�add'itiori on reverse side <br /> S <br /> t _ <br /> I hereby certify that I have prepared this application and that'the"work will be done in accordance with San' Joaquin 'County <br /> 3, Ordinances', State Laws; and Rules-and Regulations of theHorne <br /> the ; Joaquin Local Health District, owner or licensed agents <br /> I signature certifies the following. <br /> ,. % u <br /> "I certify fha.t in the 06' 6rmance of;the work for which this permit is issued, 1 shall riot employ any person in-such manner as <br /> rUFto become s�blect.,to Workman's Compensation:laws of .Califor'nia.'.' <br /> Signed--- - ----- - --- --------- <br /> ---- ---< . . <br /> Owner <br /> - <br /> - ------- <br /> Ti _ -------------- <br /> ------ <br /> By------------- <br /> -------- - - <br /> ( a f other than,owner) <br /> k _ �• -FOR DEPARTMENT USE ONLY <br /> =---------= ---- -----D <br /> APPLICATION ACCEPTED:BY----- ------ --- ATE" : <br /> _ = DATE------------------- ----------- ------------- <br /> ---------- <br /> DIVISION OF LAND NUMBER. ----- -- X_s ----------------- <br /> —•�. �w ' �� ----- ----- -------- <br /> ADDITIONAL COMMENTS- --------- -------- -------------- -- --- ---------------------------------- <br /> d = ------------------------ --------- --------------------------------------- <br /> -- <br /> - -------------� <br /> -- <br /> --------------------- <br /> ----------- -------- --- - -- ate -------- ------- ---------- <br /> Final- <br /> --- ---- - .. <br /> Final••lnspecfiion-by:._ . -- ---•------------ -- - <br /> F&5 21677 REV. 7/76 3M <br /> EH 13 24 SAN JOAQUIN'LOCAL HEALTH DISTRICT <br />