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FOR OFFICE USE; FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 73. ........... <br /> (Complete in Triplicate) Permit No. <br /> Date,Is sued_ <br /> ...................................................... - This Permit Expires Year Froin Date lssued.� <br /> Application is hereby made to.the San Joaquin Local Health District for a permit construct and install the work herein described. <br /> This application is made in-compliance with County Ornonce No. 549 and existin Rules nal kegulati, <br /> JOB ADDRESS/LOCAT ION...... ENS CT_-----_-----_---------- <br /> ....... ..............Phone.... ---------- ......_....... <br /> Owner's Name.. .. . . ........ <br /> ------- ..... . --Zip- <br /> p. <br /> ip......... ............ <br /> Address-........ 61-lilt-Y,-------- . ....... <br /> Contractor's Name_ .......... .......License ,,,Phone <br /> -- ---- .... 16�, -17------ <br /> O. <br /> Installation will serve: Residence E] Apartment ouse ❑ Commercial [] Trailer Court El <br /> Motel ❑ Other_.._..— .......... <br /> Number of living units:. .,./... ,---.._Number of bedroom Garbage Grinder..... ---Lot Size----- ..------.-Private EJ...... ........ 4 <br /> Water Supply: Public System and name_..... . . ..... ..... ....... .......­---------------------- ---- - ---------- ......... <br /> Character of soil to a depth of 3 feet: Sand F) Silt E] Clay El Peat El', Sandy Loom 0 Clay Loom <br /> Hardpan El Adobe [J Fill Material.. .... ....If yes, type----- -------------------------- J <br /> (Plot plan, showing size of lot, location �of system in relation to wells, buildings, et.c, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> [0 L -_ *�------------------ <br /> PACKAGE TREATMENT SEPTIC T Size #..X.q;__ ..........Liquid Depth.. <br /> TANK [ I . A .......... 2, f <br /> CapacityJA60- Type._,-9_...- Materiai-- jC&—7.1-------No. Compartments.45----------- ­...... <br /> Distance to nearest. Weil------7.. .... ........ .......:.Foundation..._) ........Prop. Line----......_.----------...._. <br /> ...... <br /> LEACHING LINE No. of Lines -#W3 ................Length of each ..........-.Total Length . 17 --------- <br /> 'D' Box............Type Filter Material.-I . ....... .... Depth Filter Material--.---..._....-----..--------------_------------ --- --------- <br /> Distance to nearest: Well.... PO..... ------ Foundat.i ------ --------------------Property Line...-.-----------------.-----.----._. <br /> SEEPAGE <br /> ine.... ------- __ --- ------ <br /> SEEPAGE PIT Depth...,- _--Diameter-_ Number- ------ ------------- --------- Rock Filled Yes No <br /> Water Table Depth-------------------------- ---- ----- ................Rock Size.---/-- - -------- -------------------- <br /> Distance to nearest: Well--------------- - ................ ...Foundation Prop. Line...- ------------ -------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ...............Dat e................. ---------------- ----- <br /> Septic Tank (Specify Requirements)------ ----------------------------- --------------------------------------- .. . ............... ---------­_ .. ......... <br /> Disposal Field (Specify Requirements)-------------------- --------------------- <br /> -- ------------­­ ------------------------------------------ ------------- - -- .........__----------- <br /> ............... ............ ------ ..... --------------------- ------------ ---------------- ------ ............­---------------- ------- .......... <br /> ......................................................... ......... ---- --------------------- ........... . --------------- ------------ -------­---------- ­......1­------ ---------- - ...... <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 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 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 Compenpation laws of California." <br /> Signed----- ... . .. ...... ...... ---------- ---------- - -Own <br /> ------------------------ ---- -------- <br /> (If <br /> .•..__........... ­ -------- <br /> --------7 Iiiio er t raowne <br /> US <br /> FOR DEP TME T SE ONLY <br /> ­............ <br /> ------ - DATE APPLICATION ACCEPTED BY---------- 7. ...... ..... <br /> -- ....DATE <br /> TEDATE...... .... .. .........­.... .... <br /> DIVISION OF LAND NUMBER ........ ..... ..... -------I-------------------I-- -------- --------- -------------------------- <br /> ADDITIONALCOMMENTS--- ------- ------ - -- -- --------- ------------------------ ------------ ------------------------------------------------ ------------1-11- ----- ---- .. ... ...... <br /> ---------------------------------------------------- ---- ­­. .- ­----- .......... ................1. _­­------------- --- - -------- .. .........__............. ---------- ­...­­ .1.- <br /> ------------------- ------------ ----------- ----­1----------­--- ------------ ................... ........ .. ---------------------------------__------------------­ ------- ----------- ....... <br /> ---------- --------------­­--- -----------------­­- - ---------------------------------------------- ....... <br /> Final Inspection by:----V ­ ------------ ------------------_.................. .................­...Date F&S 21677 REV, 7176 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />