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FOR OFFICE USE: fir' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT /�/r-"' <br /> ---------------------------------------- <br /> -- ---- -- - ------- ' (Complete in Triplicate) Permit No.-- --- _ 71"`5 <br /> �` <br /> -------------------------------- ------------------------ Date <br /> Issued_A�_-.e-W7� <br /> ----- _- This Permit Expires 1 Year Front...D IsgVed <br /> Application is hereby made to the Samjoraquin Local Health District for.a permit to construct and install the war herein d ribed. <br /> This application is made in compliance with C ty Ordinance No. 5 9 and e ' tg'Rula*s nd R ulation <br /> o� <br /> JOB ADDRESLOCATI ( _.. Q NSACT <br /> Owner's Name..--.-- �- *� ------ --- ----- --- • -- - ----- ----- - �--�c. -- Pho $1 ." / <br /> Address - -------- - City ----- ---- Zip----- -- -- --- — <br /> �/ - --- ` <br /> Contractor's Name -------- Et­�Ij­ __=-- _ - - -------- --- ense - T_ - Phone-- <br /> installation will serve: %sidenceM, ApciifMent-Nouse.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Ot er------------------------------------ ------ <br /> 1 ._ --------------------------------- Q <br /> i Number of living units:-- -- -----.--Number..of..bed>' _._._.�.. G�bage..Grulder__-__ _---Lot ---- ------ --------- <br /> Water Supply: Public System and name-�---------------------------------------------------------- ----------- ---------------------------------------------------------Private <br /> f it to a depth of 3 feet: Sand Silt Clay Peat , Sand Loam Clay Loam <br /> Character o so p ❑ ❑ y❑ ❑ Y ❑ Y <br /> Hardpan ❑ Adobe Fill:Majerial_.------....If Yes, type-------­----------------- <br /> (Plot plan, showing size of lot, location bf system iAioelation to wells, buildings, etc. must be placeel-on reverse side.) C <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �� <br /> PACKAGE TREATMENT [ ) SEPTIC TXNK_ Size_- ------- -------Liquid Depth. �� _jo - <br /> Water <br /> `�4 __AAateriat__ ---- partments.---------- ---- ----Capaelty 1 Type --- --- No. Com <br /> Distance to neflrest: Well_` -.-__ -__. _____-. Foundation -_ Prop. Line-------------------------- <br /> Ole <br /> _ ---.--_ <br /> LEACHING LINE No. of Lines..---- <br /> LEACHING ____-_.Leng f`:eadt line_____ -----------------Total Length __.._ 'V_- <br /> D' Box----- ...-Type Filter Material_ -_ __._- .Depth Filter Mat <br /> ...... <br /> __._ .__ <br /> 00 <br /> Distance to nearest: Well-Co ial--_-. . ____ Foun ation -_Property Line_ -______..3_Q------------- <br /> SEEPAGE <br /> _ _-SEEPAGE PIT [ ] Depth_ _-____-._-_Diameter__-_ ________Number ---_-__ __-___-___ Rock FilledYes ❑Table Depth - ---s------Rock Sire-----�--------- ---------- --------------- <br /> Distance to nearest:Well____ _________ ____--_ __ _ _,____.__,Foundation $-:- ___..________.Prop. Line---. _-___.__--- <br /> REPAIR/ADDITION (Prev. Sanitatroit Date -- ----- ) <br /> Septic Tank (Specify Requirements).--_- 1�sTt-NJ- - �f� - ---�-- _- - - <br /> �t <br /> -- <br /> Disposal Field(Specify Requirements)- - �- -•= -�--- = --- ------------ <br /> - ` <br /> - -n <br /> ---------------------- -------------- <br /> --- <br /> ------ <br /> -------------------------------- -- --- <br /> -------------------------- <br /> -----------­-------------- ------- - --------- -- - --------- ------------- --- <br /> ----------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 /> "1 certify that in the performance of the work for—which thio irmit is issued, I shall not employ any person in such manner as <br /> to b 'ect m s Compensws of rnia." <br /> Signe — >1S <br /> e <br /> BY------ ----------------------- --- -- -- --------- ---- ----_Title- ---- -- --- -- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------ -- ----- -- ---------------- ' ------- --------- ------- DATE----d - <br /> DIVISIONOF LAND NUMBER---- ------------- - ------ ------------------------------------------------------- ---------DATE------------------------------------------------- <br /> ADDITIONAL <br /> ------------------ ----------------------- ---- <br /> ADDITIONALCOMMENTS---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------- -------------------- -------- �----------------------------------------------- -----. <br /> ---------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------ - -------------------- <br /> Final Inspection by: ----- - - ---- ----- ------------ ---------- Date .� �t"L <br /> EH 13 24EALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> SAN JOAQUIN LOCAL H S T <br />