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FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> .......... ............ -- _ ? 1 <br /> Permit No.. . <br /> (Complete in Triplicate} •------=----------- <br /> Ay. Date <br /> "' Thi`s Permit Expires 1 Year From Date Issued 1 f . <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/!_OC�7lON... Fa 1 S Q .- <br /> _ ---- -- --------------------------------------------------------.CENSUS TRACT...------- .-------- <br /> Owner's Name.-.... }'RNO SaZZ-- <br /> --- - - -- .... ------- - ------- .-. ------- ------------ ------....------ - -----------.Phone.__...........•---.-.---...-- --. <br /> Address --- . .. -- f�R�-Hc <br /> :2 1 . .-- .._..:-- _...---- . .... 15 <br /> City----- 1 ---- ---. --ZiP----------- ---- --- -------- <br /> Contractor's Narr,64_.0 �ar�. /f 1 �' 'E- E• <br /> d. ... ---�.. p ---.-.. ....License #_.'ZgM4 --- .Phone...- ._3 .. <br /> Installation will serve: Residence Apartment House Commercial [] Trailer Court ❑ <br /> A Motel ❑ Other- ............. --------�--e Grinder-- ---- ---"L-- <br /> o--t- <br /> Number of living units------ ---------Number of bedrooms...3- -.-G - <br /> Sie.---_. ._ ..ag � <br /> ............:. <br /> Water Supply: Public System and name__ .... ----- ;- Private <br /> ----------------­------ - -------- -- <br /> ..- ----------------------- <br /> Character of soil to a depth of 3 feet: Sand ($ Silt L] Clay ❑ Peat E] ' Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan} p ❑ 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 INSTALLATION!, (No septic tank or seepage pit fpermittd if public sewer is available within 200 feet,) [ <br /> PACKAGE TREATMENT [ } SEPTIC TANK f a S Jb S �� <br /> f S'ize,_.. ----------.Liquid Depth------- ----------- ------ <br /> Capacity... <br /> -----Ca acitY l2vZ Typef. ..Material_ 5:_"..e- ... �- ---.--••-----.-- ---•_--- k <br /> ' Distance to nearest: Well.:... �.6� Foundation._".V r..._ ......_ Prop. Line...... . ..........._ <br /> 1 <br /> - ------ ---_--- <br /> LEACHING <br /> -- --- <br /> LEACHING LINE [ ] ;i No. of Lines ........... -----.Length of each line...._ .6.i------------- --Total Length ..�'1. .................. <br /> D' Box...-I......Type Filter Material..:t.�I`�-r..--- Depth Filter Material...._ �...-------------- --.......................-......... ! <br /> Distance to nearest: Well � ......_Foundation._._...�.�- Property Line_-.-�.r....._....................G <br /> SEEPAGE PIT {[�j�7 w Depth'"f.._. ...--Diameter--------------------Number_ ...---_....-_-__--- -..w � Rock Filled Yes ❑ No❑� <br /> r ted' I <br /> Water Table Depth---------------------------_--- --------- .........Rock Size------___------- ------------ •------ - -- <br /> Distance to nearest: Well.----------- - ---;.....--- .........Foundation------.------ . --....Prop. Line.........---................. <br /> REPAIR/ADDITION (Previ Sanitation Permit#_......__.:_-..---_. -_ Date......................... ) 4 <br /> Septic Tank (Specify,Requirements)...... ............... f I <br /> -- <br /> -------------------- <br /> Disposal Field (Specify REequirements)..............:... <br /> t ---------..-__...............------...-----------••-•---..-------•------- .---...----- • <br /> ------------ --- t <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 slaws, and Mules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> is permit is issued, I shall not employ any person in such manner as <br /> "1 certify that in the performance of the work for which th <br /> ; <br /> to become subject to Workman's Comp sation laws of California." <br /> Signed ----.-.Owner <br /> By-------------- ................... ... .-.........Title... --------- ......... ..-----.-----.-----....---...... <br /> llf other than o r) <br /> FOR DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY ` ---... . . -- -- <br /> DIVISION OF LAND NUMBER......-- -- ------DATE--------------------------- -------------------- <br /> ADDITIONAL COMMENTS....... ........ ... - <br /> ------- ---------- ---- ............. •---------------- . ------. .... <br /> ..----'....---.---- --.... ---- ---- rr <br /> 0AV ...... <br /> r <br /> ef <br /> Final Inspection by . -- ----.-Date.---..... . .�.. <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76 3M <br />