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�bio <br /> ,FOR OFFICE USE: FOR QFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT r <br /> (Complete in Triplicate) Permit No,..7..-..: -7.... <br /> ----......-- <br /> " Date Issued.2 /'L�y.7f <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 ADDRESSAC);�TI N, Sb. ..... 1 - a`yT!b --------------------------------------------------CENSUS TRACTT----------- .................... , <br /> Owner's Name....`/. ........... ..... ­-----------------•------ ----- Phone-- ................. <br /> Address------------- ---��3 ---�.. �R,c�.-z <br /> 4•�tu�R <br /> ---------- �----��- --- - - --�d�.. .. ........:.........CitY--------- -------.... -----._......-- ---- --dip---:.......--------------- --- <br /> Contractor's Name w .. — <br /> License #- .: 3 Phone.'T6 .y6a <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other............................. ................ o <br /> Number of living units:-----v----Number of bedroom s._.5;�_.'_Garbage Grinder...---------Lot Size------ .................. <br /> Water Supply: Public System and name--- ----- ------ - --- --.......Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt <br /> Hardpan ❑ AdobeX Fill Material.- ---- ----If yes, type-..,........... .... Loam <br /> i <br /> p ❑ ❑ : Clay ❑ Peat ❑ Sandy•Loam ❑ Clay L <br /> (Plot plan, showing size of lot, location of system in relation to wells, Euildings, etc. must be placed•on reverse side.) <br /> _ <br /> hINEWINSTALLATION. ."{N6 'septic tank or seepage .pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT <br /> [ � SEPTIC TANK O Size - -----------------Liquid Depth.----- -----c`- <br /> Capacity...... --------TYPe-------- ------ Mate,Tial--------------------------No. Compartments................ ... -- .. .. <br /> Distance to nearest: Well...........................................Foundation...--.---- - ..._.-.--....Prop. Line---........................ <br /> � ; <br /> LEACHING L1NE_. [J.— .No. of Lines ....----------------•...... Length of each line,............ ......Total Length .- ------------- ------............... <br /> �'D' Box............Type Filter Material-__. ---------..Depth Filter Material..................----------------------- _....`V, : <br /> Distance to nearest: Well--------------- -----------Foundation...........................-Property Line-------------.--..--__............'v <br /> SEEPAGE PIT [ ] Depth.-- -... .....Diameter-------.------------Number-------------------------------- Rock Filled Yes ❑ No m <br /> WaterTable Depth.--...-.------- •--------- ----------------------------Rock Size---------------------------_--_---------------- <br /> Distance to nearest: Well------------ ----- ---....-Foundation . -- _. .. .. Prop. Line......-......-..--._.....- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- ----- <br /> -............Date.---------..-....-..-----------------.--------} <br /> Septic Tank (Specify Requirements)........................ - - ------- ----- ' :....: _ = -..--... _... <br /> Disposal Field (Specify Requirements)-- - .. : -... Q - mil ...-=--------------- -------- ------------------•---- <br /> ----...... ------ ------- ' X �_� �-�c-� 1 <br /> ------------------------:�--- �---x .. --- ---- - 5 - .. ......._._...._.. . -_..._. <br /> a <br /> ------------------- ---------- --- - •---------- <br /> IDraw 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 Son 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 LWorkma'n's Compensation laws of' California." <br /> Signed..---- .....Owner <br /> By---------- 0,�� - Title__---------------------I----- <br /> (If other than owner) <br /> FOR DEPARTM T USE NLY <br /> APPLICATION ACCEPTED BY------------- ------ .. ......DATE <br /> ..- <br /> 76.... .._...... . <br /> DIVISION OF LAND NUMBER.-- _-- - - - - - DATI <br /> l -ADDITIONAL COMMENT - - <br /> --------------- --------- .... <br /> - ------ ---•------ ---- ------ ----- --- ---------------------:----------:--------....------------ --- ...------. . <br /> ---------------------------- ----- ----------..------- --------------------------....----------------------------- ------------------.-------------- --- ------------------------ ........ <br /> -- ------ ------y'--- -- • . -- - -- --------------- ---- --------- ... ...... <br /> Final Inspecr�on b ..... " -- -------------- •- .. - . ..Date._.. _' ".78 <br /> EH 13 24 - 'SAN JOAQUIN LOCAL HEALTH DIS ICT F&S 21677 REV. 7/76 3M <br />