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' FOR OFFICE USE: FOR OFFICE USE: <br /> ------- -------- <br /> APPLICATION 1=0R SANITATION PERMIT <br /> I Permit No....7___`�...5� <br /> �� (Complete in Triplicate) <br /> ----------- --- <br /> 1 11: Date Issued............. <br /> k <br /> .......=s.----•--------------- .............. --------- This Permit Expires 1 Year from Date Issued <br /> Appl'ication is hereby made to.the San Joaquin Local 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 /> �. , <br /> t0�II t <br /> JOB ADDRESS/LO ATION............{.---- -- - ----CENSUS TRACT.---__------------- - <br /> Owner's Name.... hone <br /> Addriess -�j�ws�,` `..... .___... ._.... ....-' µ-' Cl <br /> J � - <br /> - ..�. <br /> ---- ----------------- s <br /> - - " t ------------------- --dip-- <br /> ` License # � a, <br /> -------------- <br /> Con <br /> onractor's Name:._... --..--..--- - `'' ..f { - Phone....-.._ <br /> - ............ .. .... , <br /> Installation will serve: Residence Apar`.tment House ❑ Commer; ial ❑ Trailer.—Court,❑ <br /> Motel ❑ Other............ .... <br /> Number of living units: ...._.t --.Number of bedrooms..:�__.Gar ae G der _..__.....Lot;S ze~"_ ........ .. ... # <br /> t ------------------------- <br /> WateI Supply; Public System and nam e..... ___ � f vase <br /> El <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay Peat El—'Sondy Loam-2— Loam 0 f <br /> Hardpan ❑ Adobe ❑ Fill Material.. ... If yes,type.,.......... ------------ ....... <br /> k {Plot Plan, showing size .of lot, location of system in relation to wells, buildingsietc. must be placed Ton reverse side.) � <br /> NEW,11INSTAL;ATION: 4I(No septic tank or seepage pit permitted if public sewer is available i` within, 200 <br /> tfeet,) <br /> �PACKAGE TREATMENT SEPTIC TANK Size._........ -��.............• .-•-�----.......- -- Liquid <br /> ('J <br /> Depth----------------------------- <br /> Capacity <br /> .. -- -- <br /> i #Ca a.citY,- --- --- --- ---TYpe--•--------- .......... tNo'Compartments-.......:---------------- <br /> Distance <br /> ------------ -Distance ----- ---� <br /> C <br /> to nearest: Well =Foundation..' Prop. Line------ <br />' LEACHING LINE k <br /> i j ) No. of Lines..- -----:.--...Length of each line. 4 -- Total Length ....... •............................. <br /> "D' Box..... ......Type Filter Material.-.. . ............Depth Filter Material-------------------- <br /> --- <br /> Distance to nearest: Well----------------�'�:{ .::.Foundation--..-._...-!-------.....----Property Line..'_---_....._..... _..._.._.... .. <br /> SEEPAGE PIT ' <br /> I � [ ] Depth.. ....... .....Diameter..---------•.--.�`'"Number._--.-___-----------------•-__-. Rack Filled Yes ❑ No ❑ <br /> Water Table Depth.-- ----,- -.....Rock Size.- "....... . <br /> - a <br /> ----------•-•--- - <br /> Distance to nearest: Well-------------------------------------------Foundation----........ <br /> ..._- - - ....Prop. Line------.-.----.------.._i_ <br /> . <br /> REPAIR/ADDITION (Preva Sanitation Permit#- --- ..... .....:'- "" ''".Ijate--------- <br /> __.._ - -• _ ' ..�....._. .. ) <br /> SepticTonk (Specify Requirements)------ --- <br /> - ---------- ----------------------------- <br /> Disposa! Field (Specif, Re qu a ents) . . <br /> l -- - ----------- --- ---- - -- <br /> -------------- ------------------------- - <br /> ` y- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared tliis application and that the work will-`be done in ac roc dance witFi"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 W man's Compensation laws of California." <br /> i( <br /> Signed--- . ..`. ...............Owner <br /> fP <br /> BY---- ! . -----.... -- Title--------------------------- <br /> (If other than owner) ` FOIE DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- ---- - - - ..............DATE .--.... �.. -8 <br /> DIVISION OF LAND NUMB .. DATE................................................ <br /> . <br /> ADDITIONAL COMMENTS....... <br /> I� > <br /> ------------------------------ <br /> ----------- ....------ . <br /> ------------------ <br /> ----------------- --------------- <br /> II <br /> ...........: - -- -- -- - - - ------- - -- --- - -- - - -- - - - - .... <br /> Final !Inspection b Date.... ~. <br /> Y - --------------------------------• ------------.....----- •---- ------ ............----- ....... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />