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FOR OFFICE USE: FOR OFFICE USE: <br /> 3d APPLICATION FOR SANITATION PERMIT <br /> ------- <br /> r (Complete in Triplicate) PermitNo.�. ..��e�..p�.. <br /> Date <br /> ................. .--.- This Permit Expires 1 Year From Date Issued <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 incompliance with County Ordinance No. 549 and existing Rules and Regulations; <br /> JOB ADDRESS/LOCATION. - �'-p..... . T.... ._ ..... <br /> -- -....-- - -•- •---------------------.CENSUS TRACT-- ----.....--- - --- - ---- <br /> Owner's Name.... ._._.... e- Qom---- ---- .....--........................- Phone (9 ' 7 v.... <br /> Address_--- <br /> -------- ....._...Z. .. l- --.City--------- - --- - y--- ---............Zip-- <br /> s - + 4 � w zz -- <br /> Contractor's Name.................. License # '..l .. <br /> Installation <br /> -Io7....... <br /> ....--.... . <br /> F <br /> Installation will serve; Residence ❑ Apartment House ❑ Commercialx Trailer Court ❑ <br /> Motel ❑ Other_................ /- _ <br /> ------ LL <br /> { Number of living units:_......_...--..Number of bedrooms............Garbage Grinder.......-.-..Lot Size J � ., .. �.a.-.:�.__.. <br /> { Water Supply: Public System and name___... ....... <br /> - ---------------- ­ - -------------- ----------0-----.. .. ...--- ---0--- -;--------Pri <br /> vote <br /> Character of soil to a depth of 3 feet: Sand E) Silt ElClay ❑/ Peat Sand Loam ClayLoam <br /> Hardpan ❑ Adobe Fill Material._ --- -...If yes, type............................ <br /> ..... <br /> r <br /> (Plot 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_p t..'permitted if public sewer is available within 200 feet,] Ile <br /> PACKAGE TREATMENT �( <br /> j } SEPTIC TANK _.7" 44. <br /> • e ........... .. --�-�--- �---�---------- .............Liquid Depth.-� --------------�-- <br /> Capacity-.�/'`� i...---Type.... ..Material--- -...:---..No. Compartments _---.:-...... ------------- <br /> Qistance to nearest: Well.:--....` ..._�.........- Foundation....-. Prop. Line-47 <br /># LEACHING LINE ( No. of Lines ........ ....:......Length o ea line......... ---..-.-...-.Total,.Length _.....�...._........:---..__.-. <br /> r ` 'D' Box---..X. ..Type Filter Material.... ...............Depth Filter Material..........I _ ..`._......._-_._,T_ ,.------.,. <br /> M Distance to nearest: Well........1. rt Foundation........ Property Line: I • .. <br /> SEEPAGE PIT Depth...74...._Diameter..-3-3.st.......---Number....:-------(------.----:..... . Rock Filled YesX No <br /> Water Table Depth Rock Size- .. /--- - - --- ---------- . <br /> " Distance to nearest; Well__-.--.1.�...-........---------Foundation-...- ... . .f"-.Prop. Line_.................. <br /> t. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...........................-- ..-. ....-.........Date---._k <br /> Septic Tank (Specify Requirements)...... ............ ..... <br /> -- ------------- ....................... <br /> Disposal Field (Specify Requirements)..... ........:...: . I r�.- - : <br /> ti <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 accordancewith ySan'Jdaquin 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 employ any'person•in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed. ----- ----- Owner <br />( t <br /> By................ - -.---------------- ------ -- ----f--- .... ----------------- -- -- .. Title...-... <br /> .-......... -------- <br /> (If a than owner) <br /> " `F R EPART ENTUS E ONLY <br /> 19 <br /> APPLICATION ACCEPTED BY------------ - :-..-----..DATE ----_ _`. ... .. ........_............. <br /> - - - -- ---- ---------------- <br /> IVISION OF LAND NUMBER--- ---------- - --- QATE....--- <br /> - ---------- -------------------- <br /> ADDITIONAL COMMENTS--------------- ------- ------- --. ... <br /> ----------------- ----- <br /> Final Inspection by. <br /> ----- ... -7 <br /> Date. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes ziarr aev. 7/76 3M <br /> i � _ <br />