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,.•.��-__.tee.`-a,+cr. .��. �� � <br /> FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> �- APPLICATION FOR SANITATION PERMIT <br /> �r <br /> -------------- ---------- .............. (Complete in Triplicate! <br /> Permit No....7 / <br /> ----1------------------- -------- <br /> ------------ <br /> Issued_------------------ <br /> ............ ....... ..............:. ............. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a -piermit to.:construct•and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules`°arid Regulations: <br /> JOB ADDRESS/LOCATION.... - _- - ------------- <br /> ...... <br /> ---•--CENSUS TRAC <br /> T•..... ....:....... <br /> Phone.-- - ........ <br /> Owner's Name.... ... _ <br /> Address----------- - --- -- -------'-�-� `d�-._....... � . . _...._...City---------- ----------- •- ---- .---- ......--Zip <br /> Phone • // I .... <br /> Contractor's Name._.._. (!-I`ll._.. -- - ---- License # �_ _--------...... ✓1. 1 <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Mtel ❑ Oth-er`--....... ----------------------------- <br /> of <br /> --- ------ r` <br /> Number of living units:-----� -- Brooms -. -- ' Gar._ ge G�index-_---------..Lot Size--..-i ._x- `..�- -�--- ---- <br /> Water Supply: Public System and name--..-... - _ � - _--------------Private ❑ <br /> ___-Number of be <br /> Character of soil to a depth of�3 feet: Sand ---S-ilf"❑ Clay ❑ Peat•❑ %S'd' ncly Loam El Clay;Loam <br /> Hardpan ❑ Adobe F1 Fill Material _ ... -...If yes, type---_!- <br /> -------------- ---------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) G <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] #SEPTIC��T77ANK [ ] Size .... --4.40�A-It------------------- -Liquid Depth.._---.-------------L <br /> Capacity-.�..i �� Type ..Material._- t No. Compartments_...: .... ^..� <br /> , t <br /> Distance to nearest: Well.......... -----...Foundation...__..[ Q....... . Prop. Line........b_ ... <br /> LEACHING LINE [ ] No. of Lines . .._.. -- ..-.- Length of each line___. - ~----l-.---- --Total Length .�------ -------- ----------------- <br /> of a s` <br /> 'D' Box..._ ..Type Filter,Material.... /- <br /> -� D Filter Material <br /> .tan- Property Line-Distance to nearest. Well. <br /> v <br /> I <br /> SEEPAGEIT [ ] Depth---.-.--..--. -Diameter__._•--`�r-Number -=-------`------ Rock Filled Yes No ❑ <br /> Water Table Depth-----= "_ =s <br /> ------------------RoSize. ---�.. r <br /> -C------- --------------------- <br /> -- - <br /> Distance to nearest:.We11-- )?._1_1��. s. :..Foundation.--------- .......;Prop. Line_.......... .............. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------•- ._------------------------ ] <br /> Septic Tank (Specify Requirements)_. .......... --- -- ... <br /> } Disposal Field (Specify Requirements).._....... ......._ ------------------- __ <br /> i � c <br /> i <br /> F ................. ----..._. <br /> i ----- ----------- -------- ............ <br /> ------ <br /> ----.---... .. -N.....-_ ._-._ -------__ _-, ....----................---•------•_-----------_-..._.......-- ._....---------- ---- -.... <br /> I (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work wilt be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District, Home owner or licensed agents <br /> t 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 Workman's Compensation laws of California." <br /> Signed t Owner <br /> = - . ....... ....... -- ------......._ <br /> r ............ Title-- -- ---------- "---------- -------- ------.'------------- ----------- <br /> (If other than owner) - -- <br /> 4 F DE RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-,---- . ... .. . DATE .--._� .19........-..: <br /> DIVISION OF LAND NUMBER.`-.----- - k..-- ATE <br /> ADDITIONAL COMMENTS.......---- - <br /> --------------------- - ------- -- -------- -- <br /> ..:"'_ <br /> s. - ...------ -------- ---- ..... ....... <br /> G.e --- . .. ............................... 2:. _.._...._ .._ ....... <br /> ................ .__......--.....-------------.-.._.,.-•_ <br /> ».- �. - - Oc-(/ -- _�V-....._..._-- .. <br /> Final-Inspection b ------------------ - - -- ._ Date. <br /> EH 13 24 SAN JOAQ IN LOCAL HEALTH DISTRICT FB$ 21617 REV. 7/76 3N <br />