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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.._7-__-_.__. <br /> ---•• --------- ------ - ---------------------------- This Permit Expires 1 Year From Date issued Date Issued//:-�,�1_72 <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 /> JOB ADDRESS/LOCATION- <br /> - --G' ._.r� _ -�-- -�_ ---- ---- <br /> `:.. ,=.CENSUS TRACT----------- ---------- <br /> Owner's Name---- Phone r <br /> Address----------1 - Ci 6 53 <br /> ---------- <br /> tY T: - Zip ------ <br /> Contractor's Name_____________ ___ 1t L License #-__ 0tg ------ <br /> installation Installation will serve: Residence ❑ Apar-tment.House,[]—Commercial ❑ Trailer Court ❑ <br /> ❑ Other er_----•__-- i <br /> - ------- --(--------t--- ----- [ <br /> Number of living units___ -----_ _____Number of bedrooms-.---__.Gacbage,Grind ex_____ .__.-__Lot`Size-----.- <br /> Water Supply: Public System and name------------------- ---------------_ t Private ❑ <br /> ---.---- --- - --------- --------------------- ------ <br /> Character of soil to a depth of 3 feet: Sand Silt❑ ;Clay ❑ Peat❑li Sandy Loam ❑ Clay Loam ❑ <br /> w. <br /> Hcrrd-pan ❑ Adobe ❑ Fill Material....... If e,'s, �- -` <br /> (Plot plan, showing size of lot, location of system irr relation to wells, buildil gs, dtc . must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permrtted if p�b)tc sew r is available within 200 feet,) <br />��"•PACKAGE TREATMENT[ ]�" SEPTIC TANK�.p � � t d'-^sXyY ------------------------------Liquid Depth.-- ---_------____- <br /> �, .. t 4//) a [3] �E i � Size---- - --- �- <br /> ti �.� r..-. •� ft ti y J <br /> Ca�pacit Y_ � - TYpe:_ = )Mat ia1 --------No. Compartments----- - -------- p <br /> Distance to nearest: Well------------ ,S_Q . __--.-._ d <br /> Foundation __ - _-----Prop. Line. _- ----- -1 <br /> � � <br /> LEACHING LINE , '} 9 �—� <br /> [ ] Na, of Lines _: T, 4+� _._ Leng"th of eachlina �j� otal,len t� E_ Q- N <br /> . :, <br /> t D' Box.____.___.--.Ty%pe Filter Material__ ,--_-_' <br /> Depth Filter Matenal______________ ___ ` _ :_, _ <br /> r t <br /> [ Distance to nearest: Well-.. >%.5``?-_°__'____Found ation.__ Property Line_._, _r__'_,,,--------------- <br /> ` <br /> SEEPAGE PIT [ ] Depth---------- ----Diameter.--------------_ ---Number------------------- ,__-- <br /> ____. Rock Filled Yes ❑ No (]IO <br /> rWater Table Depth------------- Rock S zr e r I �a <br /> -------------------------- <br /> ' Distance to nearest: Well------------ ,______-__-_____.----- -- --Foundation.-- -_.---------.•--------Prop: Line----------------- <br /> SePACRT ADDITION (Prev..Sanitation Permit#--=----------- =f1__.___- --•------ Date------ - - -r- )' <br /> - - - - ---------- <br /> p (Specify Requirements) ------------ --------------------------------------------------------------=-- --------------------- ------------- <br /> Disposal Field(Specify Requirements)--__--.__-.-__- -------------- ________________ <br /> ----------------------------------- <br /> - - <br /> -------------------------- - - ' <br /> --------------------- --------•-•--------------------------- --- ----------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify Thai I have prepared this application and that the work will be done in accordance with Sam Joaquin County <br /> Ordinances,: State Laws, and Rules and Regulations of the San Joa`q'uin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "ll certify that in the performance of the work for which this permit is issued, I shall hot employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California.- <br /> Signed--- <br /> alifornia.-Signed--- -- -------- -----=- ---- - --,-------- ------------- ­--------------Owner _ <br /> By-, : = <br /> ---- ----- - --------- --------------------=---- ---- ;­--­----- ----- Title----------- --------------- ----- <br /> (If other than owner) w <br /> OR EPARTMENT USE ONLY 7 <br /> APPLICATION ACCEPTED' BY_ ----- --- DATE <br /> ---------- ----- - ---------- -----------------:- <br /> DIVISION OF LAND NUMBER: --------.--------------- ------------------------------DATE--------------- <br /> ADDITIONAL COMMENTS--- ------- ------------- <br /> 7- <br /> -- ----------- <br /> --------------------- ------------- <br /> --------------------------------------------------------- ----------- --- ----------" -------- -------------- <br /> ------------- --------------------= <br /> Inspection by::•- Date I[ ---- <br /> Final- F <br /> ---- -- ----•-- -------------- :- - -------------------------- - <br /> 7- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> I <br />