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FOR OFFICE USE: <br /> ..........._ V11" SANITATION APPLICATION FOR SANIT PERMIT FOR OFFICE USE: <br /> _ <br /> (Complete in Triplicate) Permit No....................... <br /> ... This Permit Expires 1 Year From Date Issued Date <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.... --af_`; A <br /> �.( . - ---_------.CENSUS TRACT................... <br /> ...........- <br /> Owner's Name...- .-_ ' <br /> ---- - <br /> ,__ - -----Phone. <br /> Phone. <br /> Address-- .6. - zGf <br /> Ch: - - - City. . -. ------------ ----Zip------ ----- <br /> Contractor's Name__..L--�.�-----�_��-�--�A.L.._-._--•- <br /> -- -----License Phone---- <br /> Installation will serve: Residence Pl*"Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other. <br /> Number of living units;--- -------Number of bedrooms..._ . Garbage Grinder_.........Lot Size.--.,/" � u �! -------------v � <br /> Water Supply: Public System and name__. ��,a.- q-Klrl w- <br /> .. --- •.............. --- --•---------- ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe& Fill Material <br /> If yes, type... . -------.- <br /> (Plot i� <br /> 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 [ ] SEPTIC TANK [ ) Size _ ___- .._.--:-------------------------------- -- ---Liquid Depth.-------..-.----------- <br /> - .-.� <br /> Capacity_------ ----Type---------------- .....-Material........------............No. Compartments ------. ------ ------•---- <br /> Distance to nearest: Well_--__.-- <br /> /�-�� ,, � .Foundation.-.---- /.. .. Prop. Line............ ..........<_ <br /> LINE ('�' No. of Lines _....Y.��-.Length of each line...... �- ` �� <br /> LEACHING -. Tot length _ -----------•----------------------- <br /> 'D' Box...- ......Type Filter Material...( .-oCJ4—._Depth Filter Material.. .....19� <br /> Distance to nearest: Well._ .. F (, / <br /> - - oundation - ---_... .Property Line--- ---- <br /> SEEPAGE PIT ('T Depth -� __.._......_. Rock Filled Yes ®" No <br /> p �---.��-_.Number-._---_----� ❑ <br /> :::5n� Water Table Depth....... --- - " <br /> IJ( t�1,`� Rock Size..../. <br /> Distance to nearest: Well..... 3d.`--.."� --....Foundation.....Id... <br /> ...........Prop. Line..-,�5�--------------_----- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...................... <br /> - -.... ---- -- - ---------Date-------.....-- -- -- - --- - -- -•---) <br /> Septic Tank (Specify Requirements)_. - ------ <br /> (-.-•_--- <br /> .... ------------------------------------------------------ - --------­......---------­--------- -------- <br /> Disposal <br /> ..........•----- ••--------------.-..._..----- <br /> Disposal Field (Specify Requirements).-._ i..�G r <br /> ----- ��� <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 em to an <br /> obecome subject to Workman'ns Compensation laws of California." P y Y Person in such manner as <br /> iigned..... <br /> ner <br /> 9Y------- <br /> •--- - - - - - ...Title.-- - - - ---- <br /> (If other t owner) <br /> O DEPARTMENT USE ONLY <br /> kPPLICATION ACCEPTED ... .... ....... <br /> ­­- ------------------- . f <br /> . - <br /> IVISION OF LAND NUMBER.......-._- DATE_.-. ------ -.. <br /> ---------0i . .DATE...._ ---- ---­------- -ADDITIONAL COMMENTS- ----------._...--- ' f �..._...---•--------- ---- - 1 <br /> Qf-.- l� ..1 Z... 1 -._..aDm _F9!>Y. r;J.L ft <br />....................___..----- <br /> --- •- -------- - --•- -- <br />�inal Inspection by: . .. . --- � j1 - - -- --- -- ---------- <br /> 1 <br /> i ­­------------- -------------- _---------_---Date �o _ -..7 .. . <br /> H i3 sa SAN JOAQUIN L AL HEALTH DISTRICT <br /> f&S 21677 REV. 7/76 3M <br />