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_TwZ FOR OFFICE USE, <br /> FOR OFFICE LTSE.. APPLICATION FOR SANITATION PERMIT Permit No.,7.��_/ <br /> ---------------­­---------- ......... (Complete in Triplicate) <br /> -------------------------------------------- ............ Date issued <br /> ............I.,...... This Permit Expires 1 Year From Date issued <br /> ............ <br /> fhe work herein` described.- <br /> J6a­qui`n,LZ__c&I-H_ a construct and install-A Fl-fli-uFstr,ict or a permi <br /> This application is made in compliance with County.Ordinance -No, 549 and existing Rules and Regulations: <br /> '13 C_ ..... ........CENSUS TRACT----------­ ---- -------- <br /> JOB ADDRESS/LOCATION..,........ ........ ....... ........ ....... <br /> IN . ......... Phone------- ------------------- <br /> A-1--L.�....... - --------- --------- ----------I <br /> Owner's Name. ..........Ay- 7YA_5�,v ---------------- <br /> Address-... - ------------------------- ------------------- ......city----- <br /> # <br /> Phone-.4 w <br /> License <br /> ntractor's Nam -------- �7. �)* V .... <br /> "V ........... <br /> Co e__ F 4 � <br /> I <br /> i Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court E] <br /> Other........ .. ..........1 <br /> Motel El ­........ <br /> Number of living units:-.---1.-----.--Num.ber of b drooms:._-'!F Garbage Grindar.___-------Lot Siz------ ......... ....... <br /> -------Private <br /> Water Supply: Public System and Clay Peat El Sandy Loom [9 Loam D name_---- -- <br /> --- ---------------------------- ---------- ------------ <br /> 'Y <br /> Character of soil to a depth of 3 feet; Sand E] silt(:] Clay'E] <br /> Hardpan ❑ Aclobef-] Fill Material-- _- --..If yes, type...................11.......etc. must be placed on reverse side.) 09 <br /> "showing size of lot, locati of'system in relation to wells, buildings ic <br /> {Plot plan, on 1 1 <br /> NEW INSTALLATION: -(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 31 <br /> _N� —S_r_PT If d',T size ----------------I---- -------------- --.--Liquid Depth------- ----------- <br /> PACKAGE TREATMENT ANK <br /> t.. <br /> Ca Type.?'�.G41 7"..Ma terial_ No. Compartments..... ............. <br /> each line_�T7 ........ ......... <br /> Distance to nearest.. Well-•---------------- ........ .......Foundation...... ....... Prop. Line. <br /> --- <br /> ........ _Total Length <br /> LEACHING LINE No. of Lines ......... Length of ea <br /> 'D' Box.....V!..Type Filter _Depth Filter Material----- ------------- -------------------- ---------------------- <br /> 00 f Line-------------- ...... ......... <br /> Distance,to nearest: Well.',,...----------- ....Foundation,_Zf�............------Property <br /> Rock Filled Yes ❑ No E] <br /> SEEPAGE PIT Depth........ ----_------------------------- <br /> Depth_- _Rock Size- ----------- ............... <br /> Water Table ......... ........... ... ------------------ <br /> . .I.......... ..._Prop. Line.------ . ........ ------ <br /> Distance to nearest;�Welri_! .... .......... ------------- -----Foundation <br /> REPAIR/ADDITION (Prev. Sanitation Permit ------------------------- ---------------Date ----------- ...... .. ........ ... ........ <br /> Septic Tank (Specify Requirements)....-- --- <br /> ..............I----------- ------------------------------------ .................. <br /> ------------------ ----------- <br /> Disposal Field (Specify Requirements)_ ...r`----------......................... -------------•------------•------------ --------- ---- <br /> -------------------- ...... ....... ................. ------- .......... <br /> -------------------------- -------- ------ _­.......I--------------------- ----------------- --------_------ <br /> / 4.-> _,� I ­­... .......­­........ ......... ....... ........ ......... <br /> --­---------------- ----­---------__--------------- -- ---------------------­­------- - - ----- ---------­--Ir------------------ <br /> --i'-(Draw-existing and required addition on reverse-side)--- <br /> r— i <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+Rul�es and Regulations of the Son Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following-v <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 Compensation laws of California." <br /> By_------ <br /> � f <br /> ....Owner, ------------------------ -------Signed ..... <br /> ............. ---- --- ..-------------- <br /> (1f <br /> --------------- <br /> ( f4er than owner) <br /> FOIkDEPARTMENT USE <br /> r <br /> ------- --- -------- ---- - ONLY <br /> APPLICATION ACCEPTED BY... — <br /> DATE9_17 =77- <br /> DATE.... -------_­­­­ --------- <br /> ND <br /> ER <br /> DIVISION OF _� UMB ---- -------- ---- .. ........ ......... <br /> ADDITt0NA_LJ'COMMENTS_ ......_-- ------------ ------- ----- - ------ --- --- ----- <br /> 1�, <br /> ----------------- <br /> --------- .........I......... ............ ........... .............. ------ ------ <br /> 14, - - ............. -------------------------- -------- ------- -------- -------------------------- <br /> -----------:.,­-------- -- ------- <br /> --------------- I-------- --- ----- -- <br /> '1111�_ /I _ �F --------- - ----- <br /> ---------- ----------- ------------- ----- ......Date ----- ------ <br /> Final,Inspection by:------­­.......� .. ... F&S 21677 REV, 7/76 36 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />