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FOR OFFICE USE; FOR OFFICE USE:1�1 <br /> 9 APPLICATION FOR SANITATION PERMIT, <br /> --------+a--------------------------- ------------------- (Complete in Triplicate) Permit <br /> --------------------- - <br /> Date Issued_.777.aA6_7n_ ,'�_ 4 <br /> ---------------------------------------------------- ---- This Permit Expires 1 Year From Date Issued <br /> Application 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 /> 1 7.cc6/ <br /> JOB ADDRESS/LOCATION .----—--=-------------=----------------- - -=---CENSUS TRACT---------------------------- ---- <br /> Owner's Name ti` 1 <br /> g_T/ <br /> - --- --_ - - hone <br /> Address - � -f_ City - -------------ZiP----------------------------- <br /> - a i <br /> Contractor's Name------ 4.-- --- �- -- --------------------License ` . _' . __(hone- L _ <br /> -------------- --- - - <br /> Installation will serve: Residence- Apartment House.❑ Commercial [] Trailer Court ❑ <br /> Motel ❑_�Other---'-- - " ----------------------------- <br /> Opt- <br /> --------- , <br /> Number of living units---------------Number of bedrooms_-. --_Garbage Grinder-.- -.._�--Lot,,Size_ ._. _-- -a.---.---------.----_-._--__.___ <br /> g 1 � - <br /> Water Supply: Public System and name----------------------------------------------- --------- --------.------ ----:---------------------------------------------Private` <br /> Character of soil to..a-depth of 3 feet: Sand F Silt❑ Clay ❑ Peat❑ Sandy:L qm_o Clay Loam._0,�.�;. <br /> Hardpan Q Adobe} Fill Material--. __.-If yes, type................... <br /> ______________ <br /> (Plot plan, showing size of lot, location of system in relaktion to.well s, buildings,"etc.,must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if'public.sew r is available within 200 feet,) <br /> � r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ;�- ----------�-----i__� -----------------------Liquid-De th� r------.------------ <br /> Capacity3+GO Ype� Matarial_C _Gr No. Compartments <br /> Distance to nearest:.Well_---____'___" ->-___t _ Foundation-_'____. D____ __Prop. Line-_ __ "----__--- <br /> LEACHING LINE r No. of Lines__________ _____________ <br /> _...Length oeach Iin ------ -- Total Length . 49- <br /> 'D' Box------------Type Filter Material_- _- -- p -------------------------------- <br /> r _De th Filter Materaal �- -� ----=�------ •Q., <br /> Distance to nearest: Well._-- ...Foundation--.: ©: ,°______:__-Property Lih e__=.�;------________________ <br /> SEEPAGE PIT X Depth.-Z,5._—-----Diameter-;_ _ ---------Number---!----------------------------- Rock Filled YesX• No <br /> rlRock Size_._ <br /> Water Table Depth -:-- ----------- - --��---------��;------ -- - � -- - -------------------- � <br /> Y <br /> - . <br /> /CV_!---- � _- =-.Foundation.__.Dlto l �f _-.Prop - <br /> � -------- <br /> Sanitation <br /> - -- <br /> Sanitation Permifi# ;REPAIR/ADDITION {Prev -----^-- - Date- � ---------t ----� <br /> � <br /> Septic Tank (Specify- Requirements)-------- -- -- - - --- -- ----------------- --- --- ----- - ----- -------------------- -= <br /> Disposal Field`(Specify-Req irementsl--... ---- --- -- ----------- --------------------------- = <br /> ''^r = - - 1 <br /> --------------------- <br /> ---------------------------------------- --------------------------- - _---- --- ------- _ -- <br /> : (Draw existing and-required'addition on reverse side) }_ ' <br /> 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 7 the-_ San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies'the following: { <br /> a <br /> "1 certify that'in the performance of the work-r wmliic`h thisrperrriit is issued, I shall not employ any person to suchmanner'as <br /> to become subject to Workman's Compensation laws of California." { <br /> Signed------ ---------------- -----;---- ' ----=----1--& .�=Owner <br /> BY,------------ --------- -- - --- ---- ------ ------Title------------ --i • ----------- ----- <br /> } (If t er than ownero, ] <br /> t R D PARTME T SE LY <br /> APPLICATION ACCEPTED BY---------- - - 5 - -------- ------DATE.------ = <br /> DIVISION OF LAND NUMBER-------------- -f ------ ------------. -.-----------------------------------DATE------- ------------------------ -------._.:.-- <br /> _ <br /> ADDITIONAL COMMENTS----------.--------- <br /> f <br /> ____________________________________________________________________________________________________ ______________ <br /> __________________________________ _____ ____.__. --------_._-{� T _. - .--__ __ <br /> ]- -------------------------- <br /> Final Inspection by: --------------- - -`---- ------------------------------------- -- Date_ <br /> EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M i <br /> Q <br />