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MI OR i'7FFICE USE: w�je <br /> FOR OFFICE USE: <br /> )rAPPLICATION FOR SANITATION PERMIT <br /> f l (Complete in Triplicate) Permit No._7.'I.". ...1 <br /> ... --------------- <br /> Date Issued__-6_.''_t_el_-_t9 <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 <br /> County Ordinance . 54 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .. ._ �(�.--- <br /> f �1 .��— CENSUS TRACT <br /> Owner's Name............. <br /> JJ `1 .._. <br /> /✓ _... � .. .. , ._/............ Phone <br /> Address --•---.....- �..Ci ,, /_ <br /> /v tY �` :, zip...:.. .. ............... <br /> Contractor's Name.._..... <br /> / 4A o. ---�. '-•--- . -�..... -- .._License #2.(__31,/1.Phone-----..:.. <br /> Installation will serve: Residence �p'artment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------------------------_-------- <br /> Number of living units:.... Number of bedrooms. <br /> n.-bar ale Grinder___ ___ ..Lot Size___ - � ' --------------_ ... .. <br /> C' 4/_` -� - '� _. <br /> 1 <br /> Water Supply: Public System and name---- ----�� -- ---�-�--- - L -...�....-- - •----- -- ----------------�----- - --- -----------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ill Material...---- ....If yes, type------------------------........ ' <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NF-W INSTALLATION: (No septic tank or seep❑ <br /> p-it----p�-e--r.m...i.t.t.Med�atifepublic sewer is davailable within 200 feet <br /> PACKAGE TREATMENT SEPTIC TANK ize..... -------------------Liquid Depth. / - <br /> Capacity --...Typ iaNo. Compartments....... - <br /> ..._.... ... Prop. Line../..-.._-_....- <br /> Distance to nearest: Well........ Foundation___................ <br /> LEACHING LINE Length f each line.--/Ore) - . ......-_Total Length . ............... ............... <br /> LX� No. of Lines.-�- ---_/------... -- � g - .l �C,� <br /> l <br /> 'D' Box S...Type Filter Material.. ......_.�Depth Filter Material.......�_,/f.._. .._...._.............__.._-._._..-._-_-- <br /> ista a to nearest: Well......,fl1_4...........Foundation._._./L"_/._...-..._..Property Line_.._��..................... � <br /> SEEPAGE PIT pth... ...._Diameter.....�.._.6.__Number................./____.--_____ 11Rock Filled YeZZ5 <br /> Water Table Depth------•-----1 .t ...... ....................Rock Size...... -•----- -- <br /> Distance to nearest: Well_...1Foundation ....Prop. Line. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------.--------------------------- _...._.Date-----------------------................... <br /> ,-..-} <br /> t <br /> Septic Tank (specify Requirements)--- - ---------------------'--------------- - ------------ ---------- <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 /> "1 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 subject to Workman's Compensation laws of California." <br /> Signed--------------------------------------------------- Owner <br /> By-------------------------------- �...._.. ,,� ---- ------.......Title... � ------------ --- ----- -- ------- - <br /> If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.... ..... . . . . ............--.-DATE .._3J-4—?>7-9-_._-...-......-- <br /> .. .-_ - -------------------------------------------•-- <br /> DIVISION OF LAND NUMBE ..------ ------- --------------------DATE...___..._....- <br /> ADDITIONAL COMMENTS... .................... --------------- ._...... . <br /> --------- <br /> -----------­---- .... .. -----------------V"_1-------------------------------------------------------------------------- --------- ...... <br /> ` 11 <br /> e ...... <br /> Final Inspction 6y:. .. - --------------------------- -------------- --------------------------------- -- ..........Date— ------E---` ------------------------------ <br /> EH <br /> --- -...._.----------- ----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/76 3M <br />