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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------ <br /> {Complete in Triplicate} Permit No.7�__.411__-�6 <br /> --------------------------------------------------------- , <br /> _________________________________________________________ This Permit f Expires 1 Year From Date Issued Date lssued.,7=1_f-Z� <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---- G :___ -__ ---------- TRACT __--- ------------ <br /> Owner's <br /> -Owner's Name--------------- -- -- --- ------ -------------------- <br /> ----------- ---- t/ P -------Phone----�--- ----cj'- <br /> e <br /> - Al <br /> G-� ---------------------- ----------------------- <br /> .1 <br /> t <br /> ty. ' ZipqiAddress - � <br /> Licese #ta 's Name- ---- 38zCon <br /> f <br /> Phone--------------------------- JI! <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ i <br /> MotelTO­�Other "* <br /> - --------- ---------------- <br /> I <br /> Number of living units•'_ _ .____._.Number.of bedrooms _Garbage Grind r___ Lot Size_ _ -------- -,--:----,--___ <br /> Water Supply: Public System;and name--:'�- - �_-'- _--- _-.- -- -. _.--._ .-. --; .- .Private ❑ <br /> Character of soil to a depth of 3 feet. Sand ❑ :Silt❑ Clay ❑ : PeatE] Sandy Lobm ❑Clay Loam ❑ <br /> f Hardpan❑ Adobe❑ . type <br /> es, t e--------------------------__---- <br /> (Plot plan, showing -size bf lot, location of system 'in relation to,wells, buildings,etc,must be:placed on reverse side.) ¢ <br /> NEW INSTALLATION:" (No septic tank or seepage_pit.permitted if public sewer is available within 200-feefi,) r <br /> PACKAGE TREATMENT SEPTIC TANK" ,- ' <br /> [ ) [ f Size _ = r`S y'- 'Liquid Deptli'- ' <br /> l •', : t� l-- a� : _.... <br /> r Capacity:1-1.00 --- _Materia <br /> 'Type ateri l �--No. Compartments.-,----� --------- --- <br /> Distance <br /> -- <br /> LEA Distanceto nearest:.WellG________--------_Foundat;on :...__ -----.._- ,.Prop Line___'-_-----•--------------- <br /> ` t <br /> CHING LINE [!� No. of Lines ` � Length of each li.ne.________ �_________-• .__.7otal Length ___ 1� ______________ __ <br />} ! a 'D' Box-- t " -Type Filter Material __s�___ _Depth Filter Material-------- ------. ___. _-- ____ <br /> Distance to nearest: Well -- �; -foundation--- o---- _ Property Line_.____. __ <br /> [ j p -Number __ __ Rock Filled Yes ❑ No ❑� <br /> SEEPAGE PIT De th- _ _ D.iameter__________________ <br /> Water Table bi A---=-- ---------- - Rock Size----------------------=------------- ------ <br /> € { I Distance,to'n;a&est: Well.'- - -'------- ---Foundation----------------------`_.Prop. Line------------- _------_g__- <br /> REPAIR/ADDITION (Prev. Sanitation'Permi't,#_____._--:----------------------------------------------Date--------------------------- -----) <br /> Septic Tank (Specify;Requirements) - -------- - ---- - ---- - -------- --------------- -------- ------- <br /> Disposal Field (Specify,Requirements) __________________________ ______ ________ <br /> ------------------------;------------------- --------- ----------------------------- -- - ----- - ---•--------------._--------- . _ ----- ------ ------ ------- ----- --------------L-L--- --- <br /> --------------- ------- .--- .. <br /> s. r.(ffraw existing and required addition'on reverse side) I <br /> [`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 Sari Joaquin Local Health District. Home owner or licensed agents t <br /> signature certifies the following: <br /> "I certify that in the perfoehidnce '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.". . r <br /> Signed- = #-- - ----' Owner <br /> _._ - . _ <br /> $ t --------------------------------=- - ---- :- 6 d' _-- Title s /Lk1t�[�. -------------=--------" <br /> SY - ! <br /> f (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED' 13Y' = = = ----------------------------------==---------------------=- = DATE' . ---------`---- -------- ----- <br /> DIVISDIVISION <br /> ION OF LAND NUMBER-------'------ ------ ----------- -------------------------------------.DATE------------------------------------------------ <br /> ADDITIONAL <br /> ------------------ ----------------ADDITIONAL COMMENTS------------------ --- --- --' =----- ------- ----- ----------------- ------ <br /> ' i <br /> ---------------------------------------- ---------------------- --------------- --------------------------- ---------- ----------------------------------- ------------------ ------------- <br /> -----------------------------------------F <br /> Final Inspection by _ _.�,.;,.r _ Data_ `' <br /> -- -----------------------= --- -- ----------- = <br /> - - - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV, 7/76 3M <br /> t� <br />