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I <br /> FOR` OFFICE USE: FOR OFFICE USE: <br /> ` 't .I1 APPLICATION FOR SANITATION PERMIT <br /> •---------- . <br /> (Complete in Triplicate) Permit No. ... - ......`�r�� <br /> --E..................v. <br /> Date Issued...-....."..._...- <br /> ......•--- ..... --. --- ... ........ This Permit Expires 1 Year From Date Issued <br /> I 1 <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 <br /> / OCATION-_ ...... <br /> -1-- -- <br /> - ............... ......---.CENSUS TRAC-T- . <br /> Owner's Namjle...- - - ........ =Z <br /> f <br /> ... .............................. .. ----- ---------Oone - $ --, . ® ..... <br /> Address-.- �} ��IL- ------ - city....M4,w&0k........... Zi <br /> Contractor's Name SiPrM, ----- � ------..License #----------- --------- Phone-------=-------------- ... <br /> Installation will serve; Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> 11 Motel ❑' . Other- .......... . ... <br /> Number of living units:........---/-.Number of bedrooms_2...Garbage Grinder--------.--:Lot Size._...-.. Z3_AC e_ <br /> - --- ------ ....... .. <br /> Water Supply1 Public System and name........ .................. ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt [) Clay ❑ Peat-E] Sandy Loam Pk Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material.. ---- ----If yes, type <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must.be placed on reverse side.) <br /> NEW INSTAL;ATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( } SEPTIC TANK I ) `" Size....�[?z4G7_ ,----_Liquid Depth,_`:.............. <br /> ---------------------- <br /> Ca acit/.... a..�. yP ' �""`.�� cL <br /> i p T e._...- Matarial..c•4" 1 Cr,_...No; Comrtments------ ---------- <br /> `.. w / -------------- <br /> y <br /> ' Distance to nearest: Well��.--=-�------------- ---------Foundation...'A?. ...... ......Prop. Line-_,'! .�....." .------- <br /> LEACHING LINE No. of Liries .... .....`.{ _-------.Length of ea� line _ -•-- ............. Total Le /gth .. ��Gf.------,--------------� <br /> ;Zo--o <br /> jD"Box -..-..:_.Type Filter Materia✓- -:a-.L. De�ptthh Filter Material--.---I -------------------------------_--- __...._.....-.� <br /> Distance to nearest: Well.•..`....._._.,.:y�'.. Foundation...................._..---.Property Line.............._ <br /> SEEPAGE-..PIT ! � ------------ <br /> - <br /> I ] Depth--------- Diameter.-------..-''..: Number"`---- ------=---------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth......... <br /> ..........................` Rock Size. <br /> Distance to nearest: Well:.....-•....::..........i.....__:...---..c,Foundation---...-=--.. --.._. ....=.Prop. Li.ne......-.........--......... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#......:..:..:.: - : ..Date---.`-------- .....--.--- ) 4 <br /> f y ,: .� _w __w ` :- -.. ; <br /> Septic Tank (Specify Requirements) _ <br />' Disposal Fielcil'(Specify Requirements).......-�. . <br /> ---- - --- ----- <br /> -..... -- ----- ....... ...... <br /> - --------- <br /> ------------ <br /> --- - -- <br /> f <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 /> i` Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> i signature certifies the following: ' I 1 <br /> "I certify that he performance of the workfor hlch this-permit is issued, I shall not employ any person in such manner as <br /> to become u ct to W ar p al laws, of Californi <br /> Signed7�i <br /> ... .., - .Owner <br /> 1 kBy------------- <br /> -tie.- - .. <br /> (If other than owner) ,. <br /> r ; <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION""ACCEPTED BY-.-_-fiti.�. DATE ------ --- <br /> DIVISION OF LAND NUMBER....._...`......._... ..........:.............. ...... Y..-.....=..�. <br /> .......DATE......................._..... . ........... .... <br /> ADDITIONAL COMMENTS-------- r <br /> ----------- -=---- --- ..............------ ..... ------------------- ...---------------------------------- ....-- <br /> --.... ---- .... ....................... •----------- ---- ------ _---- ------- ----- ------- <br /> ---------------- --------- --- ----- ----......------------------ ----... _ <br /> Fihal`ln"spectlon by_ . . a -----------------------------------------------------Date r <br /> EH 13 24 W $ Y _ SAN JOA UIN LOCAL HEALTH DISTRICT 6 REV 7/76 3M <br />