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FOR OFFICE USE: FOR OFFICE USE: <br /> ` i APPLICATION FOR SANITATION PERMIT <br /> .�U'!�/` ------------------ • Permit No....7..c 6.. <br /> ....._... <br /> (Complete in Triplicate) <br /> Date Issued.................... <br /> ............................. .......... This Permit Expires 1 Year From Date Issued <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/LOC A xION.._....1.-�.3V... ..................................._CENSUS TRACT....... <br /> Phone..7. .t�_1 Q. ..0- 4 <br /> Owner's Name--- .. .. ..-P�Y.1. . :.._ �./.. ....... .........•-•--�• - -- :....... ... . � - - - �--._....--- <br /> Address.... !�.'3/.--- _. .. ... .... ----­--------------_--- --- City ......... Zip .......................... <br /> Contractor's Name...------ ..... ...... ............License #.. _7lS-�� ..._Phone. . S ... . <br /> Installation will serve; Residence V Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other...... -- ------ ---- --- // <br /> Number of living units:.._../..........Number of bedrooms... Garbage Grinder._.. ...Lot Size.._.l-r:-OG <br /> Water Supply: Public System and name............................................................ .................Privateg <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeX Fill Material._ ---- .--.If yes, type................... ........... _Z <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 /> PACKAGE TREATMENT ( j SEPTICTANKp(( /D Size....S/�..5���- ....................... .. Liquid Depth....L_.y� -. <br /> Capacityj_&0d-----Type��_44Qil....Material_0dr.� .:-..No. Compartments_.--_-:.:.. ..............:. <br /> Distance to nearest: Well........ Foundation....le......-.....Prop. Line..a 5............... <br /> LEACHING LINE No. of Lines. _._c ................Length of each Total Length __ .....174...... ........... <br /> nn <br /> 'D' Box....�Type Filter Material.`��1.(C0 1�.Depth Filter Material.._../49..i�........ ................ ......r <br /> .5 ....... <br /> � <br /> Distance to nearest: Well .............Foundation....a-Q.......... Property Line-..�.1j........1,,.I ..-...... <br /> SEEPAGE PIT Depth--a.. ....-Diameter.... .....Number....._.O;-.................. Rock Filled Yes`( No❑ <br /> Water Table Depth.............I, �...................................Rock Size--.�.X�. - :._.. <br /> Distance to nearest: Well.......14-0....... ..._.....Foundation .'......Prop. Line...... .._......."""...... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.:... ............................. ...............Date................................ .-..-.--_) <br /> Septic Tank (Specify Requirements).-----................................... ............................................... <br /> Disposal Field (Specify Requirements)............ ............ •------------- ........... <br /> ................................... ..........__------ ........................... ............................-..................... ..................... -------- ........ <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 /> 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 beco s bj ct to W ma s Compensation laws of California. <br /> Signed.: .............------------_--Owner <br /> _4.Title.. <br /> � . __...... <br /> - <br /> .......By <br /> (If other tharfl owner) <br /> FOR EPA NT YJE ONLY <br /> APPLICATION ACCEPTED BY...----- - - ....... . .DATE ----- <br /> DIVISION OF LAND NUMBER...------ <br /> t_1.... --- --....DATE..----•- ---•--------- -.---- <br /> ADDITIONAL COMMENTS...............:........ ------------------------------------------------------ ------------ ----- -------- <br /> -------------------------------------------•-•----------........-- --...............-----•--------------......----•-------. ............------........_._......--•------........----....------. . ---- -- -- - <br /> ........................ ... ..................__..... ... -------•-• ---------- ----- --... <br /> ----.-.-.- - 17,Ig------ ------ <br /> Final Inspection by: ^– . : _..Date..... Q.......... ...........: ... ..... <br /> -- - ----- -- -------- -----•-- __- -- - ---------- •--- - _ - ------ --_....- ._. ----- <br /> e►+ 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 aev. 7/76 3M <br />