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FOR OFFICE USE: FOR OFFICE USE: <br /> VX APPLICATION FOR SANITATION PERMIT <br /> ........ ........................... ------------- (Comp!ete in Triplicate) Permit <br /> --------------------------------------------------------- -7 T_ <br /> _51 Date lssuecl.le9r,3z9._AK <br /> ......•....- . ••................. ............. This Permit Expires I Year From Date Issued <br /> Application is h6reby;rnade to,_ti46"San;Jooq6in L6ccil Hea'Ith. District fora permit to construct and install the work herein described. <br /> This application is. made.in compliance with Coun-ty'Ordinance.No 549 'and existing Rules and Regulations: <br /> 171? a. T, .... .. ............. .......... ...__.. .......CENSUS TRACT ------------------------- <br /> JOB ADDRESS/LOCATION <br /> Owner's Nome_ ........ -1. ............................................... Phone--- ........ZiP <br /> .....:--- - ---------- ---- <br /> s - *3 .- ­ . - — ;-- .. 1 - <br /> Addre s- -V�......�-.7. ...... .......... City- ....... <br /> - 'e--- ---- - -- <br /> Contractor's Name----- ............... ..............License #X---9/-7- / Phon <br /> Installation will serve; Residence E] ApartmentHouse0 Commercial,2 Trailer Court'E] <br /> Motel ❑ Other..... . -- -----___---------------- <br /> Number of living units:.........:.._--Number of bedrooms............Garbage Grindw......... <br /> Lot SiZ6, ......... <br /> Water Supply.. Public System and name,- - - -------- <br /> ......... ---------Private <br /> Character of soil to a depth of 3 feet: Sand E) SiltL] 'Clay [7] Peat E] Saridy Loom E] Clay Loom <br /> Hardpan f-I Adobe E] Fill Material.. ..., ....!# yes,'tiype-------------------- <br /> (Plot plan, showing size of'lot,-location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> Ilk <br /> NEW INSTALLATION: (No eptic tank or seepage pit permitted if public sewer is available within 200 feet, <br /> . ' ,_s �j <br /> PACKAGE TREATMENT SEPTIC TANk I Size /40--------- --------.Liquid Depth...51t...... . ......... <br /> N <br /> No. Compartments.:..", ... k <br /> Ca l5acity-1�P.0__Type---�14 Material... --------- ------- Q <br /> Distance to nearest: Well.'....... . . _Foundation.... Prop. Line........ <br /> _�I`................ <br /> LEACHING LINE No. of Lines Length of each line.. 12-------- Total Length . f-OP------------------ <br /> _4----------------- 3 1_� - 't 1 1. <br /> 'D Box..-, ..Type Filter Material__ Depth Filter Material...-ty----I--- ---------- ..................... .... <br /> rDi'stance to nearest: Well..-. <br /> ....... Foundation./_Z)--- --------- -Property Line----------------_ -------.--.---- <br /> SEEPAGE PIT Depth....*A 6...-Diameter----- ------------ Rock Filled Yes No <br /> Water Table Depth..-----•------------------------- ---- .............Rock Size.- -- --- -----#..I ----- ------- <br /> _41^ - - -0--- .............Foundation............ <br /> Distance to nearest: Well._._'09... Prop. Line---.- ------- <br /> REPAIR/ADDITION (Prev, Sanitation Permit#- ----- ......... . - ---------Date.'------------------------------ --�.-�) - f,�' <br /> Septic <br /> ate---------------- <br /> Septic Tank (Specify Requirements}....___....... ----------- ......... .­..............I-------- -- ..... <br /> --------------- ------- ------- ------- <br /> Disposal Field (Specify Requirements) ---- I-------- -I----------I.-I__------ ------------------- ----------­--------------- -- -- ------------ <br /> ------------- ....... ....... ............................. ----------------------------- ----------- ------- --------- ---------------------- ......... ......... ................ . ....... ....... <br /> - -- -------------------------------- ---­------------ -- ---------------- - ------------ --------- <br /> --------- - --------- -------------- -- --- ---- ------------------------_.......__I I <br /> (Draw 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 ofi the Son 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 become subject to Workman's Compensation laws of California." <br /> Signed.... -- ---- -------- ---------------- wner <br /> By --- ---- Title. <br /> (if other -------- ----------- .... .. ....... ------------- <br /> -- ---- ---- <br /> er tha owner] <br /> tA FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY... Z.............. . ------------ ------ --------- ------ .....DATE ....... ............... <br /> . . ... . ............ <br /> DATE_:._- -DIVISION OF LAND NUMBS ..... .. .. . .... ... - ------- --- -------- ... <br /> ADDITIONALCOMMENTS... ............... ---------------------- ------------------ ................. . ............. . .. .......... <br /> ............... ......... .......... <br /> .............. --------------- ..... ......... --------------- ......... <br /> ---------------- - ...... .....................---------- --------------- ---------------------------------------- ------------611;. .. ... .......... <br /> - ----- --------- ...... <br /> Final-inspection by:.. ....... --------I----------------------_----------- ------- -------------------- .............Date.-AV ....IV--- I <br /> EH 13 24SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />