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FOR OFFICE USE: <br /> i' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -- -------- Permit 'No..--7?- <br /> ------------ <br /> - <br /> o... 7?~------ -- <br /> ---------------------- -------------------- (CompleteAn Triplicate} <br /> •^ Date lssued._1�-/ -77 <br /> - -----_ This Permit Expires 1 Year From Date Issued <br /> _-_ <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 /> CENSUS TRACT--------- -------------------- <br /> I <br /> - Phone . <br /> Owner's Name._ <br /> F <br /> i 4 c�ty <br /> - - <br /> Z <br /> iP <br /> --Address- --------- <br /> ----------- -------- --------------------------------- <br /> ------ Phone <br /> License <br /> Contractor's Name_._ <br /> .. _� _ s <br /> installation$Vi it serve: Residence- s"Apartment�House El Commercial ❑ Trailer Court ❑ " <br /> Other~ ~ ------------------ _ <br /> ` ,3-----Garbage Grinder ---- --:.Lot Size-:_ ------- l jj'Z� <br /> Number of living units:__.1�-----_.__6 fNumber of bedrooms Private <br /> i i <br /> Water Supply:. ublic S stem and'name.- ------ - ---`— ,:::-- _ --------_= = = : '_ <br /> e ❑ <br /> P y "r- x ; <br /> . de_� <br /> Character of soil to a depth of 3 feet: Sand ❑ -Silt❑ Clay ❑ Peat[] Sandy Loam Clay Loam ❑ <br /> . .__. . ; <br /> Hardpan ❑ Adobei❑ Fill Material-¢,-°;__-_If Yes, type---`------'----------- - <br /> l (Plot plan, showing size of lot, location of system in relation to w','ells, buildings, etc.imus be placed on reverse side.} <br /> �-), <br /> r. NEW INSTALLATION: lNoi septic t nk or seepage pif`permitted)Ef public sewer is available within 200 feet,} f <br /> l =- - --- -----------Liquid Depth. <br /> s <br /> PACKAGE TREATMENT [ )" SEPTIC TANK„[ ] ,Size £"�" -=- - . <br /> F _ <br /> Capacity.:_-:_..... <br /> --Type---: Material =' N Compartments . <br /> 4° <br /> t Distance"to nearest:.Weli_-..__ -. s Foundation.__ _.. ------------._ <br /> :Prop.` Line__: <br /> LEACHING LINE{„ [ .] No. of Lines- :'-. ,--. --- Length of each line----------- ---- ------.Total Length.---.---- <br /> - -- - . -. <br /> Depth Filter Material--------------------------------------- --- -- -. <br /> 'D' Bax--.__--- . -TYPe Filter Material ------------------ p _. <br /> 4 c - Distance.to nearest: Well---------------- = .-----Fou ndation----_._------ ----- ---- .Propert R Line_._ -N- -- <br /> ' .,• ock Filled Yes ❑ o. <br /> SEEPAGE PIT [ ] Depth --,_-- - Diameter •-- -- Num"be <br /> --------- -- <br /> s i ck Size:------'- ------------ <br /> ------------- <br /> a <br /> -.- --Ro <br /> 'L <br /> I Distance to nearest. Well.- - --------- <br /> �-- �------,Foundation"- � Prop. Line <br /> Water Table Dept <br /> EP �- -�---=--=--------1=--'--1c` <br /> RAIR/ADDITION {Prey. Sanitation•Permit-#------------- <br /> ------- <br /> }.. ----- --_ - _.. <br /> .r� C is <br /> t^, Se tic Tank {Specify Requirements},_--;�--_.-:�=-.--�-�'=--=-= --------------------- � � <br /> --------------- <br /> Disposal Field [Specify Requi(ements)-- - C - -�----- _- - ----------------------`---- ------ ----------- ------------ ---- <br /> - <br /> a -- - - ----- _ <br /> - <br /> v . <br /> i ? <br /> - <br /> ---- <br /> i -------- <br /> ------- ------•------ ---------------- -----------------:--------------- <br /> _ _. <br /> (Draw 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 San Joaquin County <br /> Ordinances, State laws, and Rules and Regulations f the- San Joaquin Local Health District. Home 'owner or licensed agents <br /> signature certifies the following: �« ; <br /> t <br /> F "I certify that in the performbnt t work far-which this permit is issued, I sFiall not employ any person,in such manner as <br /> to beeo b' rkm s mpensation:.laws of. California." k <br /> Own <br /> er <br /> Signed" - - -- ------= " ----------------- <br /> Title <br /> ----- ------ Title - - ------------------------ ----- ------- ---- ------------ <br /> --------------- <br /> r --------BY---------- -------- ------- <br /> E If er than owner) i <br /> E ONLY: <br /> I � <br /> FO DEPARTMENT <br /> Y_.. .-�..._�-�--DATE.-- -------- -------- <br /> APPLICATION ��� ------ - <br /> ACCEPTED. BY ------ - ------ `------ --------------`:----- ' <br /> DIVISION OF LAND NUMBER------------- -- --------------------------------------- ------- ----------------- ------------ ----- E - <br /> . ..DAT -- -: <br /> ADDITIONAL COMMEN'TS------------ --- - -- ------ --------- <br /> _----------- <br /> ADDITIONAL <br /> ".E-. <br /> --------------- <br /> -------------------------------- <br /> --------------- -------- <br /> -------------- --------------------- -------- _______________Date ----- - ---- -- <br /> Final Inspection by;Y"-`-------"- "- F&S 21677 76 3Fh <br /> CH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 4,ay <br />