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FOR OFFICE USE; FOR OFFICE USE: <br /> APPLICATION FOR�SAK4TATION PERMIT -= <br /> --------------- <br /> (ComP lef;e in Tri plicate) <br /> Permit No---77` p,5_ <br /> -------- This Permit Expires 1 Year From Date Issu Date Issued__f�.�_j=77 <br /> Application is hereby made to the San Joaquin Local Health District for a perm'it.to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and exisfiing Rules and Regulations: <br /> JOB ADDRESS/LOCATION V (� ^`ter -� <br /> ----------------CENSUS TRACT-------- -- - <br /> t ------------- <br /> Owner's Name----- <br /> - --- <br /> 0� . . . -- <br /> City �1r - <br /> E ---------------- <br /> ------- <br /> Phone <br /> Address <br /> Contractors Name-_____ _-__.--_ .__---- -- k -- --- License Phone- .- . ------------------- ---------- ------ <br /> -FeO 7 <br /> Installation will serve: Residence Apartment House.❑ C miner "I Trailer Court ❑ <br /> ; w Motel ❑ Other__ <br /> Number of living units:-. _ <br /> Number of bedrooms__._ -Garbage Grinder.-. ____-Lot.'.Size -i �+, <br /> Water Supply: Public System and`name- ::.. :. : `. = - <br /> - ------------ -----'-------_------------ <br /> .--------Private�y <br /> Character of soil to a depth of 3 feet.a Sand ❑ -Silt❑ -Clay 0 Peat❑ Sandy Loam 0. .Clay Loam, <br /> ... a. - <br /> # Hardpan ❑ [ Adobe Fill Material_.._.__.___If yes, type-_-.____________ ___ __ <br /> (Plot plan, showing size of lot, location of sysiem�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 r " �' e ` <br /> 1ze-,�. �" -- -------_Li uid�De th s <br /> r <br /> - - q p <br /> Capacity-� Ype h- `"Material_ ___ '�� <br /> Distance'.to nearest: Well.__-__--__.lam-TNo" Compartments -t.____ ���` _______F__ , <br /> y -f- <br /> ------------ - ndation_ .P P. 1 ine <br /> LEACHING LINE No. of Lines- .----:- ---- <br /> Length e <br /> ach e_-_-_ �._, E•t 4k � <br /> 1 W �-' �g © Nota! Length_ : - ----€--- --- ;-- ---- <br /> ------------- <br /> 4 <br /> ter Material Filter Material--__ _____�_ <br /> Distance to nearest: (Nell__ j y�__��;r_�`.-----Foundation--_..__f __ � � <br /> r� p`E�' --------.Property Line_ "mo------------ <br /> SEEPAGE <br /> PIT p ..- ..... _. r <br /> I l �De th_..-.----- Diameter-------------------Number_---.------------_-------------- Rock Fil;leid Yes No ❑ <br /> 1 . .. .. . _ _ <br /> VlLateTable­D:epth._-. ____ ............ '------- ------------ <br /> ----,----.Rock Size.---- - r s <br /> f Distance to nearest; Well: S -� _"'" -fbuniJation` r"` "'Prop, ine.:"i____q; _ <br /> - <br /> REPAIR/ADDITION (Prev. Sanitation Permit•#--- ' <br /> r, r <br /> Septic Tank (Specify Requirements)------------------- ---- --- <br /> --_____ ` <br /> ' '-J----------------------------{# <br /> Disposal Field(Specify.Requirements)__________------------- -_ -- ___ l I <br /> -- ----- <br /> - ------------------------------------------------ <br /> . <br /> ---- <br /> ----------- ------- : <br /> ---------------------------------------------- <br /> v <br /> - --------!n---- --------- <br /> ---------------------- <br /> (Draw existing and required additidn'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: i <br /> "I certify that in'the performance"of the work for which chis peiiiiii 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- -- ---= <br /> By M <br /> -------------- ------ <br /> Tit"Ti <br /> (I'f other than owner) n . --------- <br /> - -- -------------- <br /> ------- ----- <br /> - ------ ] <br /> r FOR.DEPARTMENT USE'ONLY '' <br /> APPLICATION ACCEPTED BY-"_:_ ___ '_--DATE.-- --or <br /> _ Z- --------- <br /> ISION OF LAND NUMBER- ------ <br /> -- ------------------ ---------------- -------:---.-- -DATE------------ <br /> --- -- -------------- <br /> ------COMMENTS___________ _____ __ - <br /> ----------- -------- <br /> -- <br /> .- <br /> ------------------------- -------------------------------------------------------- <br /> e�ac <br /> ` _ �� <br /> Final-Inspection by:------- ---" a:.. .,,... : _ . _. ----------- <br /> ------- ----------- - - -- ------Dat -- ---�----- �-- --- � ; <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT fas 21677 REV. 7/76 3m <br />