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FOR OFFICE USE: FOR OFFICE USE; <br /> "-APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.77--:0.:�./ <br /> ............................. ....... --------------- <br /> Date Issued. 1._g6-2-p <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 /> JOB ADDRESS/LOCATION . <br /> ... -....__ ------- 4•Q ` <br /> .-.Ap......:-----------------CENSUS TRACT...--------- r <br /> Owner's Name.. ...- -• -- --�. ......Phone_.���� °'C3`�--- <br /> T - ------ -- --- <br /> Address Jam . ...._.-..f�✓.... �..------. : --- - City ..zip ------- <br /> Contractor's - <br /> - <br /> Name- .--..,�--,.,�.}. C:/� <br /> _ ---- --------- .---License -Q, ....Phone.------- ------------- <br /> Installation ,will serve; Residence Apartment House E] Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other......... -------------- <br /> Number of living units:....6 ---------Number of bedrooms„3--+...Garbage Grinder-----------.Lot Size_-...... .. --. <br /> ------- <br /> Water <br /> --.Water Supply: Public System and name.:..... . e Private <br /> i <br /> Hard � ----- . �,---.---------�--'--- ... -�--... ..._�--------.....Y----------�---....... -..-.... --------------- �'9j <br /> Character of soil to a depth of aneet; Adobe Silt Cla y ySand_--------------- <br /> (Plot <br /> -.----_-v..... . .. <br /> P ❑ ❑ y [] Peat Sand Loam ClayLoam W <br /> Hardpan ❑ ❑ Fill Material.. .-_< _...If es, t <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side:) <br /> NEW INSTAL.ATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC [ j r Size -. l 11 P <br /> } x / __1------------ ----------Liquid Depthi. .....------. --- <br /> -- C <br /> Capocity./ �.-.-.-Type-�!+?rpCA�`Material---------------------------No. Compartments-...-Gr -- <br /> 7 ; � .T T <br /> Distance to nearest: Weil.:`.°�7--._....:. .....Foundation..&.-............. Prop. Line-... a.. ? .....�• <br /> LINE [ ] No, of Lines..0------------- ---- Length of each lino. _ .-_-...-- Total Length .. .� ..-�J._---..-.-..- <br /> LEACHING ' <br /> e I <br /> 'D' Box..!-------Type Filter Material. Depth Filter Material/ _..f------- .'..__.._----- .- -. ----.------_ <br /> 3 ��--cam --- <br /> Distance to nearest: Well--le ..�----.Foundation.�'....................Property Line_..�0----..--_.._:._------..... <br /> SEEPAGE PIT- [J - Depth.------ Diameter-- ------------ ---Number-.------- -•---------------- Rock Filled. 'Yes ❑ No ❑ <br /> Water Table Depth---...-•------------ Rock Size.............. <br /> Distance to nearest: Well..'............ .-.------... .............Foundation.......--....___....._....Prop. Line............----------.._.- <br /> REPAIR/ADDITION (Prey. Sanitation Permit#---------------=----- ......... --.............Date.........-------............. <br /> Septic Tank (Specify Requirements]...... _._I------------ <br /> ---------- --=--- ---------- ----------------- - ---------------------- ------- - <br /> Disposal Field (Specify Requirements)..................... f <br /> ---- ----------------------- ----- -------•------- ----•------- <br /> V <br /> ----------- <br /> ----------•-------------- ----------....................... ---- --- - -------- -------- <br /> (Draw existing and required addition on reverse side) y <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 t ark n's Cam sensation laws of California." <br /> Signed.... f `........ --------------- -- --Owner a <br /> By..... ;r --------- -------- --- Title.. ............ <br /> (If other than owner) <br /> i OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------..- ----------- DATE . � r <br />!DIVISION OF LAND NUMBER - -- <br /> --------------------- .. .... DATE=-........... ....... <br /> ADDITIONALCOMMENTS-- ----------------­---------- ------------- -------------------- ------------------------------ <br /> ---------- <br /> ---------- --------------- -- ------ --- ------- - -------------- ......................... ------------------- -------------- - - ------- --- ---- <br /> = --------- - -------- - - - ------------------------- <br /> Final Inspection by . -- ..... .•---.--..Date_ --- 4 <br /> - - . ------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT C17 F&S 21677 REV. 7/76 3M <br />