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FOR OFFICE USE; FOR OFFICE USE.. <br /> IAPPLICATION FOR SANITATION PERMIT p- <br /> (Complete in Triplicate) Permit No.,�a-,............. <br /> �� <br /> .. _.... <br /> ��....... This Permit Expires 1 Year From Date Issued Date Issued -,r �r.7f <br /> s <br /> Application is hereby made ta-the Son Joaquin Local Health District for a permit to construct and.install the work herein described. <br /> This application is made in cojnpliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION..-__ I •......3... ! -.......W.:-...-.. r, y /dh <br /> ii l ts. .-. !!�. ....�('.� �.,ONSUS TRACT.......... ....... <br /> Owner's Name.......... ........ .. .h <br /> ...... ...... ......:. ................ .......... Phone... <br /> Address e� $ �� _1/ ___ - <br /> c3 �v C. ./2C.t....- C ' p <br /> Contractor's Name - �- 1 ` ------..license # Phone.. - <br /> ----- <br /> Installation will.serve: Residence ❑ Apartment House ❑ Commercial C] Trailer Court El Motel F71 Other-._" atr iffil' <br /> Number of living units':..._r ........Number of bedrooms.. Garl�age Grinder---.--------Lot Size----- <br /> -----------..c3. <br /> Water Supply: Public System and name............................... <br /> ........... ---- . ... ........................... -----------r--------Private <br /> Character of soil to'a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam Clay loam ❑ <br /> + 'an Hard <br /> - pi ❑ Adobe C] .' Fill Material....:-; ....If yes, type........................ <br /> (Plot plan, showing size of lot,'location of system in relation to wells, buildings efc`musf be placed on reverse side.) <br /> NEW INSTALLATION: <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet,l f h -:- <br /> PACKAGE TREATMENT j } SEPTIC TANK pQ Size.-----.�1.20,:jA_h�- ---------------------Liquid Depth..----�-�---- ...... <br /> i # Capacty.�.aOQ------- Type- !^P fps. --Material.-C_Qi�tCl^s" C'...No. <br /> I Q_ Compartments.........�-----r-.---- <br /> -- ---------- <br /> Distance to nearest: We!!_:..-..--- .......__ ....Founda`ion.- Prop. Line-.. S <br /> LEACHING LIN: <br /> -Ea <br /> [' No. of-Lines........-.Z--------=..... Length of each line---- .Total Length � l`.. <br /> D' 1 Box_.. .._,...T Yc 110c .._Type Filter Materials ..-- epth Filter Material---------- --- - ..........-..-__..........-... <br /> Distance to nearest: Well-----_:. ......Foundation......,i�l.� <br /> - �' --------------Property Line-......> !�..----------- •---� <br /> SEEPAGE PIT [ ] Depth.".......... ...Diameter--------------------Number --------------------- Rock Filled Yes ❑ No ❑ <br /> Wate4Table Depth------------------------------- . ----•:......Rock Size..... - <br /> ..... -----... <br /> Distance to nearest: Well-------- <br /> .:......................4 .............__........Prop. Line---- :-. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--..--- 14 <br /> -- -------------.................... Date................. <br /> .---. j `r <br /> --- <br /> Septic Tank (Specify Requirementsi--------------.------------------------- -mow <br /> :..... ................I.........=------------- .... -- -------------- --...---- <br /> Disposal Field (Specify Requirements)...................... .-..-----.---.--.-- <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 /> "I certifythat in the it M <br /> performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become su" tQ W rkmdn's Co ensation Jaws of California." <br /> Signed:---;' - <br /> -------------- <br /> ...._Owner t ` <br /> By..... ---- ......Title..... ---------------------------- I <br /> II <br /> (If other than owner) 3 <br /> i F R D ARTMENT USE ONLY i <br /> APPLICATION ACCEPTED BY----'�-.-•. - DATE .--.... .-. .� -75" . ............ <br /> DIVISION OF LAND NUMBER......--- ........ <br /> - DATE <br /> -- <br /> ADDITIONALCOMMENTS.. Ig------------ ---------------•------------....--------------- -------------------------- ---------------------------------------I----...--- I ----- <br /> -------------- - --- ----------- --------------------- - --- ----------------- ._ ---------...........-...................-------------- -- .................. ......-- - . <br /> -----------••-------- ------------ ----- ------- i--- ­------ ---- .......11 -------------------- ------------ -------- <br /> ---------------•--.- ------------------- -- M <br /> -------------------- <br /> .------------------------------------------------- <br /> Final lnspe6on by:--- -c.))- - . -----------•---------- ---Date------ --- -- -----...._....... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />