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FOR OFFICE USE: f` , FOR OFFICE USE: <br /> 'e �:APPLICATIION FOR SANITATION PERMIi�, <br /> ." 7 <br /> (Complete in Triplicate) 4" <br /> Permit <br /> No.... <br /> -------------------------------------------------------- p. <br /> This Permit Expires Date Issued_..�'�-............` �� <br /> ------------------------------- res 1 Year From Date Issued <br /> rA' plication is hereby made to the San Joaquin Local Health Districtffor a pe t. o c6n�truct and iristall # eiwork he ein de ribed. <br /> . . <br /> This application is.made in complicince with C unty Ordinance No; 549 and existing Rules`.and Regulati :s <br /> y <br /> JOB ADDRESSAOC N.. ? 1--6— `= -- ----------------- ----------------------1------CENSUS TRACT-------------------------------- <br /> r Owner's Name.-.-(., .1re'y-------- ��1 L_----- ------'----------------------------- --------- ------------Phone----------------------------- -------- <br /> y <br /> Address ------------ ----- -- - Cit Zi <br /> Y --- Zip------------------ ----------- <br /> Contractor's Name------------ -_-- 1 _i_. i -�j . ---License #- :7� - (Phone--e- ja = <br /> ` Installation will serve: Residence �artment.,H Luse.❑ Commercial ` Trailer Court ❑ <br /> Motel ❑ Other------------------- ----- - <br /> Number'of living units---------f____Number of bedroom --Garbage Grinder -_Lot Size____ <br /> Water Supply: Public System and name- =---------------------- ---------- - ---------------- ------------ ---------------------------------------Private [ice_ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt0 Clay ❑ Peat❑ Sandy Loam,❑ Clay Loam ❑ <br /> Hardpan?❑ Adobe ill Material------------ yes, type----- f---'---------------- <br /> y (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc:•rtiust be placed on reverse side.) C <br /> isNEW INSTALLATION: (No septic-tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> I PACKAGE TREATMENT [ ) SEPTIC TANK � ize_----�_ , _________:._________________Liquid Depth---- --�----�--- <br /> :__ <br /> Capacity- ateial� DCompartments______- <br /> -_- <br /> ------------------ <br /> YP f <br /> r7 , <br /> D' #ante:to nearest: Well-_-__-- -------------------------F ndatiorr.'�/.) ___-. Prop. Line_-- /-------------- <br /> --- . _-. <br /> I_ ! J <br /> LEACHING LINE No. of Lines____ :- Leri th of each line <br /> „g Totc1l Length __ <br /> 'D' Box- ---Type Filter Material_�� ------Depth Filter Material-----,��---------------------------------------------------" <br /> . -------.Property Line____------- <br /> Distan #o nearest: Well--__.�----___________Foundation----- -_�-�__ ._ I ______________ <br /> -- f, <br /> SEEPAGE PIT Depth&ir_____Diameter"- <br /> ------- Filled_ Rock Filled Yes{ moo❑ <br /> 71 <br /> / ''�.•�� <br /> Water Table Depth---- ---------/-w----------------------------------.---Rock Size--- <br /> Distanceto nearest: Well--__- ._____-_-_________________Foundati,on__ 4----__ Prop. Line__ ---____-__-. <br /> ._ REPAIR/ADDITION (Prev. Sanitation-Permit#---------=------------------------------------------Date------=---------------------------------------) <br /> SepticTank (Specify Requirements)-------------- ------ ------------------------------------------------------------------------------------------------- ----------------- ---------------- <br /> DisposalField (Specify Requirements)--------------------- ------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----- <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 Son Joaquin County <br /> * <br /> Or State Laws, and Rules and Regulations of the San 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 rrlanner as <br /> t to. become subject to Workman's Compensation laws of California." t <br /> r- <br /> Signed--------- --- Owner <br /> BY-------- ------- <br /> r r Title---- .�s., - ------------ <br /> ' (If other than owner) <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -_-- ------------------------DATE._--- --- � . _ -- <br /> - - -- -- -- ----------------------------------------------------- - <br /> DIVISION OF LAND NUMBER----- ---- - - -----------------------------------=------ <br /> ` <br /> - - ---------------------------------------------------------------- <br /> -----------------DATE <br /> ADDITIONAL COMMENTS---- -- - <br /> F <br /> ------ <br /> _ ---------------------- <br /> -------------__ . -________-_-___-__----____________-__________-_________________-______---___-_--_-___-__-__--__-__--____- __--____-----____--_-__-____ <br /> ______________________________________________ -__-__-__-_____________________--_____-_-____-_______._-______-_______.___-____________-_______________-______-_________--_______.---------- <br /> ------------------------------------------ <br /> ____-_-__ <br /> _____________________ �`_. <br /> Final Inspection by ! =r Date. � --d � <br /> ------- <br /> EH;13 24 r-'.. SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 RE 76 3M <br />