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xt�ll <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------- ............ .... ....... ----- Permit No <br /> (Complete(Complete in Triplicate) <br /> ...........----------,...--•----- __----------------- <br /> Date Issued.__R.,._ <br /> ............. ........................................... This Permit Expires I Year From Date Issued r <br /> Application-is hereby made to.the Son 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 /> TRACT.- <br /> -r�;o C, ck_T�41e' ..........CENSUS <br /> JOB kc _f -A.g ......... -------- --------- - <br /> ..... . ............. ....... . ...P,--- ------- <br /> L <br /> Owner's Name. ------ ....... .......... ......... ...... .....................Phone.....­­_­............. <br /> Address------------drA94A.70-fVf.---81/ ...... ..................... .............. ........Zip--- ---------- <br /> Contractor's Name... --.License <br /> .. . ....... ---Lice ----------------- Phone...---.-...... ... ------------ <br /> Instal lation.wil I serve: Residence E] Apartment House E] Commercialg Trailer Court El <br /> Motel ❑ Other-. .--- ----- ..................-1---------- <br /> Number of living units-----------------Number of bedrooms..-.- Garbage Grind&r------------Lot Size------__............. .. . .. ---------- <br /> ---------------------------------- -------- -7 <br /> Water Supply: Public System and name---- ---_------- --_---------- Private <br /> ---------- <br /> -----_- <br /> Character of soil to a depth of 3 feet: Sand Silt[-] ClayEJ Peat E] Sandy Loam [I Clay Loam 0 <br /> ,.Hardpan ❑E] Adobe ❑E) : Fill Material....... 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 permitted if public sewer is available within 200 feet } <br /> SEPTIC TAMC [-J­ JE)0#,5TJAr16t�.......... ------­------------------------ .........Liquid Depth.. ........ ....IN <br /> PACKAGE TREATMENT <br /> Capacity - ------Type----------- --------.. Material--.-------- --------------No. Compartments.................... --------- <br /> Distance to ne est. Well------_----------- -- -- ---------------Foundation--- ----- -- .............Prop. Line.--- <br /> ine...... --------- <br /> LEACHING LINE No. of Lines EV!. !_fV.ggth of each line--------------------- --- ---Total Lenth .. .......................... <br /> 'D' Box........ Type Filter Material. ..................Depth Filter Material.:..-....----------....,_.... ..___---- -Distance,to nearest: Well---------`..................Foundation--------------------------_.Property Line......-.------------.--.....-- -4SE PIT Devth.­.. ......---Diameter.....................Number----------- -------------------- Rock Filled Yes ❑E] No <br /> &X.4 Tat"eff)Table0Depth._......---- -------------- -- ---.-..---_--------.Rock Size------.... .. ----- --_----------------- <br /> Distance to nearest: Well------------ ------ -------- - ------Foundation----- <br /> -----Foundation__- ...... .. .._.Prop. Line----- <br /> rev. Sanitation Permi;#----- ---------­------- ------...Doblate....----_---- ---------- ---- ----- <br /> Septic Tank (Specify Requirements).... ------- <br /> -------------------- ------- <br /> . ... <br /> Disposal Field (Specify Requirements).- <br /> ------------------ <br /> ....... <br /> ---------- <br /> ..) ...... ....�V_�'Z kc r0_00- 37r_Jr -fie X e- <br /> .....ar1----------------------------------- ----- -------- ------------------- ---- ----------------- <br /> (Draw existing anc required addition on revers-6 sidb-) <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 Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> 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---.. 71- V---- ...............I.................. ...­­-Ow11111 <br /> % , , ... <br /> By..----=- ...... ........ <br /> ...................... ------------ .......... ......... .......... ------------ --------- <br /> - <br /> (if other than owner) <br /> TOR DEPARTMENT USE ONLY <br /> 111111 <br /> fi -DATE <br /> --------------------- ........... <br /> APPLICATION ACCEPTED BY-----/,.Ze-, ........DATE._....-...---------- ------------ ------------- <br /> DIVISION OF LAND NUMBER................... -------------- ----- ------ ------ <br /> ADDITIONALCOMMENTS....--- ---- ---- ------------------------------------ ------------------------------ -------------- ---------- -_------Z.......... <br /> .......... J------- ........................ .......... ......._........ ...... ...... ..._.................................................... L.... ...... <br /> ti .: ___--_.;-----------:_­ - -------- ----------------------I-------- ------------------------------------ ----------- ------ <br /> . ...................... ........... -------- ------ ------------ ------------- <br /> ----- -------------------------------- ...... ------- .. ----- ­ .......­ <br /> ............... . �7 <br /> -------------­- ----­---------- - <br /> "Final,Inspettion by ..... . __ ----------- - ----------------------------------------- ------------- ----------Dote --- --- - <br /> F&S 21677 REV. 7/76 3M <br /> ER is-se,- - SA JOAQUIN LOCAL HEALTH DISTRICT - <br />