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-max a FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.,7�--' <br /> ------------------------------------------ (Complete in Triplicate} _ <br /> ----------------- <br /> ------ - - <br /> Date Issued f.11 =�� <br /> This Permit Expires 1 Year From Date Issued <br /> ----- <br /> / ( f 0 <br /> 1 <br /> Application is hereby made t oche San Jod. <br /> aquin Local Health District for a permit to construct and install the work herein describe <br /> This application r made in compliance with County Ordinance No. 549 andleexisting Rules and Regulations: <br /> E K <br /> .�...H. I_s <br /> _ -. <br /> � ' ---------- <br /> owner's <br /> y _ <br /> �f.-2G <br /> = <br /> - -.-CENSUS TRACT <br /> ON ADDRESS/LOCATI } - ph. <br /> - `s --y----- <br /> Owner shame Zip--Git . <br /> ' <br /> Address-------------- ------ one.License c � -Ph <br /> -- <br /> r! <br /> Contractor's Name.:----- .� . <br /> Installation will serve: Residence [�partment House ❑ Commercial E] Trailer Court El <br /> t ' ' Motel..❑ Other--- ---------------------=----- '------- <br /> Nu�mber of living units:.___-a"""___Number o#..bedrooms.__3--"-Garbage Grinder-_ Size_- -- ------ ------------- <br /> Nu <br /> - - } <br /> _Lot <br /> : <br /> _, --Pr1v <br /> ----------------- ------ -- <br /> Water Supply: Public System and name---,--,.,----.-,- ::--- .:----'------,--: r <br /> Ch' depth of 3 feet: Sand ❑ -5i ❑ ;Clay ❑ Peat ❑ Sandy Loam ❑ ^Clay Loam ❑ <br /> Adobe. Fill Material._.-- ----If yes, type------------- <br /> -------- i I <br /> Character of soil to a de <br /> � � .Hardpan ❑ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 3 <br /> NEW INSTALLATIONc (No:septic tank or seep get per miffed if public sewer i available within 200 feet,) 41 <br /> ;r ' - <br /> -------------Liquid Depth-._ <br /> SEPTIC TANK [ I : ' Size______ "_ - i <br /> 4 PACKAGE TREATMENT `[ ] �} I <br /> I '.-Material---44r-szc '- Compartment --- - Q <br /> z No <br /> Capacity--- ..0'v-------Type ���_JI <br /> j � Foundation..; _1 Prop. Line �------------------- <br /> ----- -� <br /> istance to nearest: Well =. -`„- 11 <br /> ~� Total Length = f 7 <br /> LEACHING UNE ._[. No. of Lines._- ,__{ L._ ----= .--___'Length of each 11©e ------- <br /> Depth en M 1 pp �r <br /> i e Filter , <br /> s p aterial--- --- " - --- <br /> - -- - <br /> D' Box. � Typ i <br /> t s rte•-rf ' . . �(� / t ' Propert <br /> Distanc1to nearest:Well.- _" _-----Foundation" - p <br /> SEEfPAGE PI '' �� ---Number_________^ ~~ j Rock Filled Yes ° <br /> t € T [ Depth_" `, l' `p amete '--_ 3 -- r € <br /> F , ` <br /> - .. e 11 1 �-S=� ---- Rock Size' - . !, <br /> Water TableyDepth- = f - - f. . <br /> ------Foundation.._ - � --- -. .Prop. Line <br /> D;stancetrnearest: Well_________ _------------------ <br /> P-7 <br /> ____--- "--------1 .7 . - -----`-=-----Date----- ----- --�- -- --------- <br /> REPAIR/ADDITION (Prev..:Sanitation Permit#____i_ -. <br /> z z # _----- -------------- --- - : ---------:---------- --"------------------------------- <br /> Se <br /> ------- ------- 4 <br /> Septic Tank.(Speu#y Requirements)---- ------------- <br /> - <br /> Disposal Field(Specify Requirements) ... ...... <br /> ;. .j,.---- r <br /> 4' �.h <br /> $ ;9 - ---- - --- -- <br /> ° ------------------- ----- - :: <br /> ---.---------------- <br /> -------------Jf <br /> ---- <br /> (Dravv-ex•isting and required addition on reverse si e} <br /> i <br /> I hereby certify that ].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: tf such manner <br /> "I certify that in the performance of`the work for which this permit is issued, I shall not employ any person in s ,as <br /> to become subject to Workman's Compensation: laws of California." <br /> ! f --------- -- -Owner. <br /> B = :; -- --------- ----- <br /> Signed - <br /> Y �. <br /> - •------- --- -- - •-1-� -- ---- - � Title---- - , <br /> (if other than.owner),F <br /> PIT <br /> t FOR DEPARTMENT USE ONLY' <br /> - D <br /> APPLICATION ACCEPTED B - ATE `fJ M -- <br /> � �, -- --- - - -- --- ---- DATE.---- ----: -- -=---- ------ :------- -- <br /> DNISION OF LAND NUMBER--------------- - -------------------- <br /> -------------------------ADDITIONAL COMMENTS----------------- , ;"_ ------------- -------------- ------------ ---- <br /> t ----------- --------- - <br /> -------------- 1------- -------- --------- <br /> ----------- ---- <br /> ------------------------- <br /> __ <br /> ---- --------------- <br /> --------------- <br /> ---------------------------------------.............- � _ .... _ Date_-1�� r 31-�-�� --- ---'"-- <br /> Final Inspection b --- ------- --_____-1---•- ------------ --- <br /> p y%------------ -- F&S 21677 REV, 7/76 3M <br /> FH 13 2a _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br />