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.y <br /> I oaf 11 <br /> FOR OFFICE USE: FOR OFFICt USt: <br /> OPLICATION FOR SANITATION PERMIT17 <br /> ... <br /> .............I.................... .. ............ Permit No., <br /> (Complete In Triplicate) .... <br /> ..................................................:....... <br /> _ <br /> Date lssued..9..:�,V ?19 <br /> . . <br /> ............................. ...... ......... This Permit Expires I Year From Date Issued <br /> Application is hereby made to.thii Son Joaquin Lo.cal Health District for 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 and Regulations: <br /> JOB ADDRESS/LOCATION..,......... ... .... ............ ........I...............................................CENSUS TRACT.................. . .. <br /> Owner's Name ...........................a...... ...... ...................7..........................Phone.0,745...!�VY.5— <br /> ... ............ ..Zip.................... ........V <br /> Address........... ...... ....... ........................................City.,T <br /> 67'�� <br /> Contractor's Norrle-.. ..................................."...........License Phone.43T. ..Y.A577. <br /> Installation will s.erve: Residence Q p A partment House [I Commercialf] Trailer Court El <br /> M6tel other. ... ....... ........................ <br /> Number of living units:... ..........Number of bedrooms:' � S Garbage Grinder...... .....Lot Size......... ................. <br /> Water Supply: Public System and name................ ...­:............. ................... ....................................Private <br /> ............... ... <br /> Character of soil to a depth of 3 feet: "'Sand Silt❑ Clay 0 Peat 0 Sandy Loom [3 Clay Loom 1r4 <br /> Hardpan ❑ Adobe [Dt Fill MaterialA. .... ....If yes, type.............................. . <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALkATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I I SEPTIC TANK I I Size ..................Liquid Depth...15_5; .F.... . ..0 <br /> ..........................No. Compartments......:Z. .......:.......... <br /> Distance to nearest: .... .........Foundation..cp.1!) ...Prop. Line.................. . ..... <br /> LEACHING LINE No. of Lines:, ;Z�7 ' '9721...�f I— th ...... <br /> ....................Length Length of each line.. .............Total Leng <br /> 'D' Box..(:... Type-Filter Mate'rial..14-1.k <br /> depth Filter Material.-.... V..... .... ............ ........ ... ......... <br /> F .......Property .�— <br /> Distance7 to ounclation...SEEPAGE PIT Depth... ....... ......... .......Number-.....r.................------ Rock Filled YNo <br /> Water Table Depth.............::`......................:...:...............Rock <br /> Size....:........................................... <br /> Distance to nearest: Welh.,.............. ......................... Foundation-,.............. Prop. Line............... .. ....... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....... ............................I..........:....Date.................... ... ...... <br /> Septic Tank (Specify Requirements)...... . ....... <br /> .............................;...... ................. ... ... ........................................... ..... .... <br /> DisposalField (Specify Requirements).................... ............................... ................................................. .................................... .......... <br /> Ar <br /> ........................................................ .I... ..................................... <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 San Joaquin County <br /> Ordinances, 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 manner as <br /> to become subject to,Workr qan s C 10 rnpensation laws of California." <br /> Signed........ <br /> . ..t`................ ................:Owner <br /> By................................ ............................................... <br /> .......................... Title............................................... ......... .......... <br /> (if other than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY......: .. .. ................ ................ .DATE ... <br /> DIVISION OF LAND NUMBER............... ... .......... .........................:; <br /> DATE................... ..... ..... . <br /> ADDITIONALCOMMENTS. .................. .............................. ....................:..................................................... <br /> I - <br /> ............................ .... .................. .. ....................................................................................................................... <br /> " . <br /> .............................. ............. . ............. ...............................- <br /> ....................................................................................... <br /> ........... ..... <br /> .............. ......................... ........I.......... ........;�- . <br /> Final Inspection by:....... . ................... ... .. .. .... <br /> ....... .........Date . F&S 21677 RIV 712a 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT CP <br />