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1 <br /> "FOR OFFICE USE, FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ` <br /> --------- ----- -------{` ill--------------- S 7 <br /> (Complete in Triplicate) Permit . <br /> --------------------------------- <br /> Date Issued_. 0-:2- <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: _ Y <br /> r, �j f , <br /> JOB ADDRESS/LOCATION . . --/eS-- :� -/ ------- ...... h---- ff� h CENSUS TRACT " #- <br /> Owner's Name `� t .1-j°k' +'a-------------------- Phone---- ----�'. 2r 1 <br /> Address---- ------------ ---- --- -y=Z == ieXAk'1-91Z& itY ---- -----------------Zip---------------------- <br /> Contractor's Name--- ---- ------+------.-0490-h--- - - ------����i(_Z------License #_,3-��---------Phone <br /> Installation will serve: Residence; Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> g i Motel ❑ Other------------------------ ---- ----- ----- ------ <br /> T <br /> Number of living units:____ ___'__----Number of bedrooms',.---_----Garbage Grinder_ _- -_Lot Size------- ------- ------- <br /> WaterWater Supply: <br /> Supply: Public System and name------ --------- - -----------------------------------------------.---._.____ ----- =--------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ r Peat ❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ .�, Adobe ❑ Fill Material------------If yes, type-------------------------------- F <br /> (Plot plan, showing size of lot, locatign 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 /> NtCKAGETRtATMENT [ ] SEPTIC-,TANK [ ] Size-----=-----------------------------------------------------Liquid Depth--------------------------- <br /> %• % <br /> ` Capacity----- =------ ------Type----------------------Material--------------------------No. Compartments----------------------------------- <br /> rl <br /> I " "' ' .- Distance.to nearest: Well....... :...... =------- ------Foundation -------------•-•=---- -Prop. Line--- ------ "J; <br /> LEACHING LINE_ [ } rNa. of Lines-'------ ----- ------------Length of each line-------------------------____.Total Length.---.----- <br /> ' D' Box------------Type Filter Material--------------------Depth Filter Material---.-------------- ---------------- ----- ---- ------s--- <br /> Distance to nearest: Well_,______._._____---_-_____--Foundation----------------- ------.Property Line--..----.------------- .. <br /> SEEPAGE P 7 ['j I`q,{Depth----------------Diameter--.------ ------Number-----------------_--_-_--------- Rock Filled .Yes ❑ No ❑ <br /> � .. ; <br /> j' Water Table Depth--'-.-------------------- --.Rock Size------------------------------------------------ t <br /> Distance to nearest: Well--------------------------------------------Foundation--------------------------Prop. Line------------------ -------- <br /> RE IR/ADDITION (Pr, ' . Sanitation Permit#--------- -----------------------------------------Date------------------= ---------------------- <br /> Septic <br /> --------:-------- -Septic ea y=Requirements]--------------------- - <br /> Disposal Field (Specify Requirements] _. ✓.:`-'. : . ---------------------------------------- <br /> ------ ------------------------------ - <br /> ------------------------ ---------------.--------------------- ------ ------------------ ------- <br /> = ------------------ <br /> (Draw existing and required addition on reverse side) f. <br /> hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin.Coun <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 sub' t` Workman's ompe satioxi laws of California." <br /> ,p <br /> Signed ----- -------Owner t <br /> BY-------- - `------�J^ - ------Title------ <br /> ------------ ----- -------------------- <br /> (If other than owner) <br /> ` FOR DEPARTME T•USE ONLY <br /> ] <br /> APPLICATION ACCEPTED BY_ --- - -- _------DATE . ----2�Y- -- - <br /> -------------------------------------- -------------------------------------- <br /> DIVISIONOF LAND NUMBER.- ------- --------------------------------- --- ------------------------- ----- ----- ----------DATE.--------- --- ---- -------------------- _ <br /> ADDITIONALCOMMENTS----------------- -------------------------------------------------------------------- ------------------------------------------- --- ------------------ <br /> ------------------------ ------------ -------------------------------------- ----------- <br /> ---------- <br /> -------------------- <br /> �o r <br /> Final Inspection by:�-✓-- !` ._ --------------------------------------------------------- ---- Date_ -fes <br /> EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT E&5 21677 REV. 7/76 3M <br />