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FOR OFFICE USE: FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> (Complete in Triplicate) <br /> No. .............. <br /> -------­------------- <br /> Issued_4.';__7.-7 <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 /> A; <br /> JOB ADDRESS/LOCATION. . ----- .... .... ... .. . .. -. -. -------...---...--CENSUS TRACT...------. ..-_--............ .. <br /> Owner's Name. .......... .. lJ ..-------.... Phone. 7a= `Sr <br /> Address L7A.. : .....CitY -----...... Zip--------r <br /> - ------ --- ` <br /> Contractor's Name---.... . ...._. ---.License #_���.�.�/_ -Phone.y6._- '"��!� <br /> Installation will serve: Residence Ne Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motes Other- - -------------------- ---- <br /> t <br /> Number of living units:.... __.---Number of bedrooms... arbage Gh der. _._--....Lot Size_,52... ../.�v:............. .... .. <br /> ,�Q ------Private <br /> Water Supply: Public System and name +C. .-. ��.. ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom [3 Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material.. .... ....If yes, type <br /> Mot 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,} O <br /> PACKAGE TREATMENT [ ] SEPTIC TANK iz ...� �� -------- Liquid Depth.lf.._....___ <br /> Capacity/p��}.Q_--__.Type- No. Compartments.---------- <br /> Distance to nearest: Well.-------~f,�. . �..Foundation._.04_------- <br /> ....Prop. Line_ *4;� .. <br /> LEACHING LINE For No, of Lines ......./------.--------- QQ Length of each Iine� ._ t <br /> 9 - - ----- - - Total Length - �Q�............... . ..•-• <br /> 'D' Box............Type Filter Material jriDC/�.bepth Filter Material_ --/ ----_ <br /> ,• � � <br /> Distance i--------- <br /> to nearest: Foundation. .....Property Line.........r. .. ........ ..._..__. <br /> -- - <br /> ( ] Depth._Ad-.•....Diameter.o?*.O�/�fumber......../------------------- �r Rock Filled Yes R4--�No <br /> / t Rock Size._ 0. <br /> Water Table Depth.---- •----- --B-C�- ......................... t <br /> A;rIt <br /> Distance to nearest: Well ._ �®� �.... �....... -- <br /> �• iw� Foundation_._I�--Q- Prop, Line... <br /> REPAIR/ADDITION ]Prev. Sanitation Permit#................................... ............. Date.................................. .-.--------) <br /> Septic Tank {Specify Requirements)--- -•------------• ------------- -------------- <br /> - <br /> Disposal Field (Specify Requirements)...................... .............. ............................. <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 <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 4ic <br /> toors Cam ensation laws of California." <br /> Signed---------- ...... -.-. Owner <br /> By----------------- --- -- - ---- --------- Title- / -- .._...----------------- -- <br /> ]If other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ ------------------------------------ -----------------------------------DATE .----- --(--�..Z_7\770� <br /> DIVISION OF LAND NUMBER.----.-- -- .-- DATE----------------------------- <br /> ADDITIONAL COMMENTS-- ----------- ....... --- ------------------------- -- ----- <br /> ------- - - -----•- <br /> --------•-•-----•- ..............: <br /> Final Inspecflon by:---- .. lL -��------------------------------------------ --------------------------------------Date..._-.- �7.. .. S2--- -FSS 21677 REV. 7/76. 7/76 - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 3M <br />