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FOR OFFICE USE: M APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> F <br /> .._... 77 <br /> � (Complete in .Tri licate} Permit No.� ................. <br /> Date Issued.../a��f' . <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 Count Ordinance No. 549 and existing Rules and Regulations: <br />` JOB ADDRESS/LOCATI N. e�- r� CENSUS TRACT. <br /> Owner's Name.. . • ----- Phone. <br /> Address.... d..o2.�J�� 5-/_.--r: -G.LO. --........ City .... --Zip -� /. <br /> Contractor's Name..- '� C .-- License # 1. ..`3- - ..Phone...Inp_ +�/.b.... .. <br /> Installation will serve: , Residence a}---�Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> A Motel ❑ Other....-_.-.------------------------------------ <br /> Number <br /> -----..._. _Number of living units:.... :-.'°---Number of bedrooms.--�Y. _....Garbage Grinder............Lot Size.. ................ <br /> Water Supply: Public System and name_ ::........................ .. _---- -- -------- ------Private' <br /> r Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe . Fill Material.. .... ..- If yes, type------------------------------- <br /> -- <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 ize., �o .. /a........."-_Liquid Depth..)"-- <br /> _----:-- ....--_-----. <br /> Capacity/60C0.....-Type -. .Material------- - -------•""-•-- :No. Compartments <br /> Foundation.. ...�:. ............ Pro Line... .. .-- <br /> ,, Distance to nearest: Well------- ----------- -----L-,--- pp -� p;.r.. <br /> LEACHING LINE �(f No. of Lines ....Length of each line...Q--15 ....9.._-L-"- Total Lengthf..,.-- ®-�------------------ <br /> 'D' Boz....✓ .1�..Type Filter Material Depth Filter Material--- Com."---''---"...... •---.--- -°---- ........ <br /> Distance,to nearest: Well.....�7 - <br /> rr <br /> ------------ Foundation.-2o..----------_---Property Line_.J�---- -.._-.....-........... <br /> � <br /> SEEPAGE PIT Depth:_4; .�f_. -Diameter..3.4-.........Number-------0Z................. .. Rock Filled Yes No <br /> Water.Table Depth------ --aa--------t-----------------------------Rock Size._ ..3..... --- --------------•- <br /> t <br /> Distance to nearest: Well---- Qd"---------------------------Foundation_.4.4-d-------- <br /> .---.Prop. Line.._.c`? -.. ........ ..... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----- ----------------------- ...........Date.....---........I----------------------------- <br /> Septic <br /> ---------------- -----------Septic Tank (Specify Requirements)...... ........... . .... .... . <br /> I Disposal Field (Specify Requirements)...... . .......•-- - ------ -- <br /> -------- --------• <br /> -------- ---------- ----- ---- <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 <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, 1 shall not employ any person in such mann r as <br /> to becom su ject to Wo�an's C pensation laws of California." <br /> Signed----.h-- ".` �- -----t <br /> ----- -- -------- --Owner . <br /> �' Title..- C � _.... - <br /> (If other than own ) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...-.---"-. .- .........DATE ..._....L�`l/..- ---------------- <br /> DIVISION OF LAND NUMBER. - - ------------------ ATE ------------------ ......... --------- <br /> ADDITIONAL COMMENTS- -�f i ----- --�-------- ...._k. /f :�1.. .t'. .------... <br /> Ct <br /> ------------------- --------' �1- - ----- - <br /> .... . <br /> ------------------------- <br /> Date. - <br /> Final lnspecilon b 7/76 <br /> EH 13 24 �. SAN JOAQUIN LOCAL HEALTH DISTRICT F8S 21677 REV; 7/76 3N5 <br />