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' FQR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ----- --- 7 S� <br /> .-.._-. --„-- _ �_ _ (Complete in Triplicate) Permit No.. --- .. -. <br /> -^ .--�-- <br /> . ... •--•"- This Permit Expires'1 Year From Date Issued Date Issuecl.s.43��77 <br /> Application is hereby made to-the San Joaquin Local Health District for a permit to construct and install the work herein describ <br /> This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: ed. <br /> JOB ADDRESS/LOCATION._.......•------- ------ { • <br /> CENSUS TRACT. -- '. <br /> 1 Owner's Name ---..1�� - �� - _...---- <br /> Address........ : .. 29 7 <br /> ... G d 0 one <br /> -- - <br /> C;ry. . zip <br /> Contractor's Name _. ........... ... ��-- ....... <br /> -:---------------- ---=---- ----- <br /> Installation will serve: . License❑#..--....�.�- -..-•.- --- <br /> V Residence Apartment House ❑' Commercial <br /> Trailer Court ❑ <br /> Motel ❑ Other..... <br /> Number of living units... <br /> ------Num'ber of bedrooms-_ -. arba a Grinder Lot Size.__ <br /> - -,..-..--- ZF�k .� .-- <br /> /r ------------- - <br /> Water Supply: Public System.and name.._ .-..---••-__...•_ . - _-. � �- <br /> --------_- • --------------------------------- <br /> -- -------Private El' Character of soil #o a depth of 3 feet: Sand ❑ Silt❑ Cla <br /> Hardpan [] Adobe ' y E]. Peat ❑ Sandy Loam El Clay Loam ❑ <br /> Fill Material-- If yes, type-.-.-'-..--•..... <br /> i (Plot plan, showing size.of-lot,..loca.tion.-of.s.ystem in relation-to-,wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No 'septic tank or seepage <br /> pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT E ] SEPTIC TANK ]' SiL <br /> z - F ------ - -----• - -• ---Liquid Depth.__. <br /> Capacity -------Type- Material----•- ' _-- <br /> �- --_No. Compartments----- :dZ- <br /> Distance to nearest: Well-------- ---„--- -.. .:------- Foundation_ --. <br /> Prop. Line <br /> LEACHING LINE ' Y' <br /> No. of Lines...-_..__. Length of each line...10-e---,----------Total Length ., ..�Q-Q. , --------- '- 1 <br /> 'D' BOX... _.....Type Filter Materials=--�U..- Material.. <br /> - �---Depth Filter ---...�8 ---------- - � <br /> - ----i . <br /> Distance to nearest: Weil-. -..------_.Foundation--.�Q-- { <br /> --------Pro Property Line <br /> SEEPAGE PIT ► rr / P y . <br /> f7 Depth-..a2 ..-..Diameter-_.-7 ----.......Number--------------------------- Rock Filled Yes, ' No <br /> r <br /> Water Table Depth.--.....-. �-- <br /> ---------------- .--_Rock Size..-- <br /> , r-�,, n� � �.-- ----. ... a-�,�------------------- ----- <br /> Distance to nearest: Well.-..---....f.L�-----_-_ 4r e <br /> Foundation_...�cS.---... - Prop. Line...5_... <br /> REPAIR/ADDITION (Prev.:Sanitation Permit ,--.-.-- <br /> f - _ :.'--------...Date.-....-.:...__ ) <br /> -- ---------- <br /> Septic Tank (Specify Re`quirements)---... _-•--. <br /> Disposal Field (Specify Requirements)_--- -• ......, r <br /> --- <br /> -•---.---`--------------- <br /> ---- -------------- ' � <br /> t -----•---- ----------------------•-_---------------------*------------------•---- _•'• -' <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that;l 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 /> ' 4 <br /> "I certify that in the performance of the work for which this Permit is issued I shall not employ an <br /> to become suP P Y Y person in such manner as <br /> War an s Compensation laws of California. <br /> Signed_..... ” %10 <br /> /� Owner <br /> BY if�'`' .........,Title.. e <br /> Of other than owner] <br /> OR D ART NT USE ONLY <br /> APPLICATION ACCEPTED BY-'_...... - . -. -----.---.•DATE.....-- <br /> DIVISION OF LAND NUMBER-_--'._.....- _ ------- --- <br /> ------- -------DATE.----:'-- ---- <br /> DITIONAL COMMENTS- ---- --- ----- ------ '- --... ,.--....-- .....- -...-- <br /> -------•-•- •----- --------- ...........................---------- -------------............................. ............ <br /> ----------------:--------- <br /> Final fnspectlon by;. .. - ---•----------•-----------•---------- <br /> --------------------------------- ---------- ------..--------•----•...- Lam,_-- . ff - <br /> -.--------•--•------•----------- ----------Date - �a--:---.---'...... ...... ... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH,DISTRICT FaS 21677 REV. 7/76 3M <br />