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FOR OFFICE USE: FOR OFFICE USE: [ <br /> APPLICATION FOR SANITATION PERMIT .76-6 <br /> 6_6 s <br /> ------------------------------------------ Permit No...--- ---- <br /> (Complete in Triplicate) <br /> "--"------" .Date Issued-.-. ._.��_"�O <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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION--------------��,- ----1�---7_? - _ -------------------- -----`-- <br /> CENSUS TRACT ------- ---------------- - , <br /> Owner's Name....... �__..—D — - ---------­----- - ---- Phone --------------- --- - <br /> R <br /> Address------ -------------------------- ------- ------ ------ ------ J ------ / ----------- <br /> Contractor's <br /> ---------- ---`��-- �-� --------�' City..l-3 --,�'?�1 .'----.- Zip. .. <br /> 1 i ,� G License #- .�11_ Phone:cxc ...._ <br /> Contractors Name...-----4? �' ': -------------------.- + <br /> Installation will serve: = Residence Apartment Hou$ -. Commercial ❑ Trailer CoL tti❑ <br /> �❑ <br /> 1 Motel - --------------------- <br /> t' 7 <br /> 11 <br /> Number of living units:__'/....:.._..Numb+�r of bedrooms._" e Grmdea..._____-_:_Lot Size_ I�----. --.._.---_E-------------------------- <br /> Water <br /> ------ --- <br /> Water Supply: Public Sy&-m'and name------- --- --- ------- `-----------------------------.-.------------ --- --- =----- : -_ Private <br /> --`- <br /> Character of soil to a depth ofa3 feet: Sand ❑ S1t',',❑ Clay ❑ Peat L11Sandy Loam Ll :Clay Loam E <br /> i Hardpan E] Adobe Fill Material-- --------.If Y6s, type--- ---------------------------- �j <br /> (Plot plan, showing size of lot, location of system -in e'elotion to wells, buildings,-etc. must be placed on reverse side.) <br /> NEW INSTALLATION:. '(No septic tank`i or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [!.] "Size_-...`______________ <br /> -- -- <br /> - ---- ---------=--Liquid"Dept „ <br /> ' <br /> CDapauncic.teyn o5—<e=a=--r-e-sNTeYJ1Pe '- t �+---- � ---Material .----- -: --------------- Compartments <br /> ------------11-------- <br /> --------------- <br /> ------------- <br /> -- <br /> ---- ---- <br /> ------ -- _ <br /> -..__ Prop. <br /> y , <br /> ._-- Line <br /> =----= - ------- =Nafe --------I each line To#al Legth <br /> LEACHING LINE D' - <br /> Box Type Filter cArAn Depth Filter Material______ __ ____ _T . _. -__-_ --.._. _ ....__- <br /> i " _ <br /> Distance to nearest: Well Foundation -...._.. ..Property Line-:....... . . .... <br /> Depth .. i __Diameter +:. - tVber�-�--------` Fiiled. Yes E] No <br /> SEEPAGE PIT [ ] p - ---- --- <br /> ' <br /> I/Vater Table:DepTh___�------: ,�t - _ -- ..Rock Size.-_ ------- .- ------- <br /> . Distance to nearest: Well_-- i-----------------------------------Foundation—----------------,------.Prop�Line'------- ------------------- <br /> kv <br /> Y - <br /> REPAIR/ADDITION {Preva Sanitation-Permit,#.._.------- -- " .Date ------------------ - --- T.-- <br /> Septic Tank(Specify Requirerilents,)—_--_---7 .-� - 6�L 7? 1 . '- --�- -- --- <br /> Dis�posal Field (Specify Requirements):-; --_-- /d C) C G/---- �>1T�Cz- <br /> rs ------&------- ---- <br /> -------------- <br /> ------ - ------------------------------------------- ------------------- ----_-- <br /> = <br /> � <br /> P '(Draw existing and required addition on reverse side) <br /> hereby certify that-.l-have-prepaed this appljcgtion and that the work will' be.done,in laeclordance with Sari Joaquin County <br /> Ordinances 1 State Laws, and'Rules and liegulations of the San Joaquin Loid Health''DistFictt. Home owner or licensed agents <br /> signature certifies the following: H4� A. <br /> r <br /> "I certiy that in the perormance cif work for which this permit is issued, I-shdill not employ any person in such manner as <br /> - v <br /> to become `subject to W m s Compensation laws of. California." <br /> Signed-- =-------- . ------- . _ 1---Owner. <br /> BY-- ------ '�` Titl�e�� - - <br /> -- - -------- - ----- '� <br /> I (If other than owner) <br /> �1 <br /> t. . ;, ..., { .. .:. . . ROWDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED-BY---- -- .. DATE. --- ----- - - , <br /> DIVISION OF LAND NUMBER: = - = .__DATE ..- <br /> ------- ----•-• � ----------:'.. - . <br /> ADDITIONAL COMMENTS = � - -- --------- ----------- <br /> --------- -------- ---- <br /> - ---- - - ------ --- ------------------------------------- -------------- . <br /> I --- ----------- --------------- I <br /> � � ------ ------------------------ <br /> .. <br /> Final E Inspection•by:�./S - - Date "'"�' REV, 7/76 3M <br /> F&5 21677 R <br /> EH 13 24 SAN JOAQUI LOCAL HEALTH DISTRICT ' <br /> E _ <br />