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FOR OFFICE USE: r FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------- ------ <br /> (Complete in Triplicate) _Permit No.76�=,7,211____ � <br /> Date Issued..y_1/.7:, . -� <br /> .-.--....___.._..------ '.___,..... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> j <br /> ti <br /> JOB ADDRESS/LOCATION --����� ---- ---------------------,CENSUS TRACT----------- ---- -------- <br /> -- -- <br /> --------- ----------------- <br /> Owner's Name ---- _ ----------- ---------------:------------ = ---------------Phone <br /> r. , <br /> Address City--­;2!�'-o� _ Zi <br /> Contractor's Name--------- • _ - z 2,� # I <br /> - License # g Phone----------------------------- <br /> Installation,will serve: Residence ❑i Apartment House [3 Commer ial ❑ Trailer Court ❑ <br /> Motel-.0 Other.:.- f�' ,• -r. ••,. . <br /> Number of living units:__;_ Number.of..bedr o'm's2­* GarbagddGGrinder-_ .-.--..Lot:Size.... - ------------- - "'................. <br /> Water Supply: Public-System-and-name---- ._.- -------3---:_ ------'------------- -` -------.----------------------.:---------------------------- --- -------Private 0� <br /> Character of soil to a depth of 3+feet: Sand ❑ Silt❑ Clay ❑ Peat Sandy Loam ❑ 'Clay Loam # <br /> i Hardpan ❑ Adobe ❑�Fiil 1111a•terial:_:..:.....-If yes, type- -------- -- ------ '' <br /> (Plot plan, showing size of lo.t,'location of;system in relation to wells, buildings, etc'must be placed on reverse side.) { <br /> NEW INSTALLATION: J­t(Norseptic,tank eepage=pit permitted if public sewer s available within 200 feet,) <br /> PACKAGE TREATMENT' [ ] "SEPTIC TANK """ ""Tn� _ "' + -- <br /> f l Size - Liquid Depth.;- - --------------- <br /> A. r Capacity-----".------y- 1.!TYPe --Material--- ----- ------- No. Cornpa-rtments - -----4--------------=------- <br /> Distance to_nearest: Well.------------------------------------ - Foundation Prop. Line r <br /> LEACHING LINE [ ] No. 'of-Lines---_.--------------------- .Length. of each l-ins--------------------- :-----,Total Length------------;-------r.------------------- <br /> f D' Box r Type Filter Material---------------------Depth Filter Material------------------- <br /> �. :. <br /> 'Distance nearest: --- - -- _- Foundation - _ ,.L�ine-------------- <br /> ------- y ------------- <br /> SEEPAGEPIT DepthDiameter-`-- - - Number_ - --------------- Roc Filled Yes ❑ No <br /> i <br /> Water Table Depth Rock Siz --------------------------------------I <br /> al S <br /> �- Distance.to nearest: Well----------------------------__............Foundation.--------------- Prop. Line----.------------.----....-.� <br /> n <br /> Date--------- ------- ----------_-----] <br /> REPAIR/ADDITION-(Prev, Sanitation hermit#.....:.:..:..... .:.:............................ -_______-. <br /> Septic Tank (Specify Requirements)..................... ------------------------- <br /> Disposal Field (Specify Requirements)---------------------'- - , ------ ------ -------.---------------=- - <br /> -- -------- -- <br /> -----'-------------------- ------=---------------- a� <br /> --- --------- <br /> - ------------------------------- -- <br /> ---------------- <br /> ----------------------------- -- <br /> ---- ---------- `2 I _`}'--� ` 1 = = ' y <br /> (Draw existing and required ac ition;o- everse side)Y <br /> I hereby certify that l-have-prepared this application-.and that the work will be done in accordance with San Joaquin County j <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 /> 'q certifythat in'-the I t <br /> performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become.subiect .to Workman's Compensation, laws. of California." t <br /> Signed ------- --------------- -- --- = Owner <br /> BY- ---- ,+ � � . -'-Title--- �-------------- <br /> ------ ------ -------- ------- i <br /> (If other than.owner)- . t <br /> FOR DEPARTMENJ USE ONLY i <br /> APPLICATION ACCEPTED $Y_.--- -- DATE'.----- ------------- <br /> DIVISION <br /> ---_--3-:- <br /> DIVISION OF LAND NUMBER: _ .: r-,=;;;. - ---- - DATE :--- ----- ------- = - ------t--- <br /> ADDITIONAL COMMENTS--.--:----- =-------- --- --------- ---------=------'------- ----------------------------------- ------------- --------------------------------- <br /> ------ <br /> ---------------- -- <br /> ----------------------------------------=------------------- <br /> --- --------=------------------------------------- ------------------------ -- ------------------------------- -------- -=i <br /> ---- <br /> ---------------------------------------- --- - - -- --- -- - <br /> -- -- --------- <br /> Find] Inspection -------------- Date <br /> EH 13 24 ! SANJOA LOCAL HEALTH DISTRICT Fa,s 21677 REV. 776 3M <br /> t <br />