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FOR OFFICE USE: t FOR OFFICE USE: <br /> ...........-------------- ---------- APPLICATION FOR SANITATION PERMIT ff'--3 L <br /> (Complete in Triplicate) Permit No.7$��- <br /> ------------ ---------------------------- ---- -- <br /> Date Issued_/-Q_-/O--.? <br /> ___•.......................................--_-------.-- This PNrmit Expires 1111Year Frain Date:-sued <br /> Application is hereby mode to-the San Jaquin Local H alth Di trict fora permit to construct and install the work herein described. <br /> This application is made-in.complplianc�erwith County Ordinance No.. 549 and existing Rules and Regulations: �g <br /> JOB ADDRESS/LOCATION. `-..-7..1: ff..... --------------------------- -- ------CENSUS TRACT...-L-�.9---- - 1 <br /> Owner's Name.... .. . Li � <br /> �'Ir /fib/ ....... ........ . ...... . ........ ----___-_--------- .... Phone .J7� - <br /> Address-;? 3- ;�7------- > ,.___. __ ...__..._. _-. -.Cit . . .- -------.- <br /> Contractor's Name.....C"�G l --- - -- License # �, - ----- -- ---. Phone-..., .- <br /> ......---.... ........ . ........ <br /> Installation will serve: Residence❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- - - .._._- <br /> Number of living units:.-'--..__________Number of bedrooms............Garbage Grinder-- .#-------Loft Size- <br /> ----- - - --- ------------.--••-----Private -� <br /> Water Supply: Public System and name__+a.- if Cloy Peat Sand Loam Cloy Loam ❑ ❑ <br /> Character of soil to a depth of 3 feet. Sand ❑ Silt❑ y ❑ ❑ y ❑ Y <br /> Hardpan ❑ Adobe ] Fill Material.- --.. ....If yes, typ;e--_.----_------------- <br /> A <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 pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ----------------------------------------------------------Liquid Depth.---- -- - .----- h <br /> Capacity------ ---- -=------TYPe--------- ------ - Material------....-- --------------No, Compartments------------------- ---------- -- <br /> Distance to nearest: Well--------------------- ----- --- .........Foundation------.._. . -.._.- -.....Prop. Line_.--------- <br /> -- ------------! <br /> LEACHING LINE ( ] No. of Lines --_--� --- _-r:Length of each linB.:---._-=-_t-----------------Total Length ... .....-------------._-...... <br /> ---------Q , <br /> 'D' Box..... -- .- Type Filter}Material..-..:. .....Depth Filter Material--------------------------------- ----- ------- ------- <br /> Distance to nearest: Well.­­­................... Foundation------------. -------------Property Line--------------.--------.--.......... :I <br /> Depth.­ 1k Rock Filled Yes No <br /> SEEPAGE - [ ] -...'.Diameter......... .........Number- -----------------------.---------­----- ❑ <br /> Water Table Depth.._--. ----`------ ------ ------ .-------.Rock Size---- --------- ------ ------------------ i <br /> Distance to newest:Well_----={--------------------------......Foundation......... ..............Prop. Line------ ----------- ------- ' <br /> J <br /> REPAIR/ADDITION (Prev. Sanitation PeAf#-------- -------------------------- ---- .......Date_-----..................-------------.-------] <br /> Septic Tank (Specify Requirements)--------- ----- --- -- - ---- -.--.- -J". <br /> Disposal Field (Specify Requirements) ............__...---- - - --------------.._----._.._._..--------------------- <br /> ........... = ...... <br /> 4 , <br /> --- -- -- --------- - ----- ----- ----------------------------- ---------•- ------------ -------------- -----------------------•-----------................ --------------- ------ <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' accordance with San Joaquin County 1 <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 ec to Workman's mpens I s f. California." <br /> Signed. ...._ ....... ...... ..Owner 3 <br /> --------By--------------------------------------------------- --- --- ----------- Title... - ---- ------- ._._...---- <br /> w <br /> (if other than owner) <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- /- ----- <br /> DIVISION OF LAND NUMBS DATE --------------- ---- - <br /> ADDITIONAL COMMENTS .......... --- ------ <br /> ......:f---------------------_ .. <br /> - <br /> -- <br /> ------------------ ----------------- - ------------ ---------- - --------- ------------------ ------------ ............. _ ---------- <br /> Final Inspection b ' "� ----Date.--1j_._-_•---------- <br /> P35 21b77`Rf�V�7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1` , <br />