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FOR OFFICE USE: FOR OFFICE U5L: <br /> ' APPLICATION FOR SANITATION PERMIT <br /> -- -----------=------------ -- - ---- Permit No.-- -• •--- <br /> T� (Complete in Triplicate} ��•~- <br /> 9 . L <br /> -------- ------- ------------------- <br /> Date Issued____ <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 /> JOB ADDRESS/LOCATION------------- --...4. d__ l CENSUS TRACL-----_-r-------------------------- <br /> Owner's Name---- '------------'�-.a---jr-d- ----•---=-------- AVf hone.'..`.-/! 'O <br /> Address.------------ Q------ ---------- <br /> -- ,.r- CtY .3sS <br /> Phone_- <br /> Cantractor's Name License #. a ..._._ ?�1 <br /> Installation will some: Residence P.-'Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> -Motel Q Other_.'-­--­----. <br /> Number of living units:_r___--._...xNumber-of bedrooms-33-Garbage Grinder--------- Size_.__._:,.-. -__--_---..--_•__•.•----_•----- -- -, <br /> Water Supply: Public System and name---------------- -.----- -_ _ --_-------_------Private (� <br /> Character of sail to a depth of 3 feet: Sand ❑ Silt❑ Cloy ❑ Peat❑ Sandy Loom 20'-Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material-_ -__. -.-_If yes,type--------------------------------- <br /> (Plot <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 avaiia le within 200 feet,} <br /> PACKAGE TREATMENT ( ] SEPTIC TANK ( ] Size.-.. ___- -_._X_..- -------Liquid Depth--------------- <br /> Capacity- � __T e_ _ TC 47 Amateria#-----•------------------.-No. Compartments._..-------...-- -.....__---...._ <br /> Foundation_.-`_.. .Q---- --. .-_ Pro Line__.. -----w <br /> Distance to nearest: Well �� ---------------------• .,.--.Prop. 5�. <br /> LEACHING LINE { ] No. of Lines.._.__..-- --=----..Lengt�f each line:_---_ _p4.---Total L�e99th ., _ �. "--------------------- - <br /> *� y <br /> 'D' Box-_---_------Type Filter Material-1_a..�_ '5Depth Filter Ma Trial____._______---------------•--•---... -. <br /> Distance to nearest: Well-.----i--�- -----------.Foundation._ .---------------Property Line...-------------------_---------- <br /> _--_• ___---- _--_--- -- <br /> SEEPAGE PIT [ ] Depth----------------Diameter.--------------------Number..----_---------_---------------- Rock Filled Yes ❑ No <br /> J% n FSize------------------_--------------______•-------- <br /> ' Prop. Line------ -------- <br /> -------- <br /> Water Table Depth ---_----------- -------------------------------­--------Roc <br /> Distance to nearest: Well-------------------------------------------Foundation-----------••---------- -- <br /> r <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------- ------------ ` ----Date------------ <br /> ) <br /> Septic Tank {Specify Requirements)----- ----- - ---------- <br /> Disposal Field (Specify Requirements)-----------------------•------------------------------- <br /> ------------------------------------------------------------:--------- -----•--- ---------------------------------- -------•-•----------- <br /> I (Draw existing and required addition on reverse side) <br /> 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 Son Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the pe ormance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject t Workm Com tion laws of California." <br /> Signed --- ...... <br /> - r --------------------------------- --------Owner <br /> fFTitle - ------------ ------ ---------- <br /> 4 BY -- --------------------------------------- -------------------------------- - h, <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- --- -------------------------------- .--- ,DATE .- <br /> -- --- -- ------------------------------------- <br /> DIVISION OF LAND NUMBER.-------------- ---- - -- DATE =.. .._..__.. <br /> ADDITIONAL COMMENTS----------------------=------------- <br /> - - --------------------------------------------- <br /> •------------------------- <br /> l -- --- <br /> ' - -- --- -- ate fi��' - <br /> Final lnspecr�on b �j� D ° <br /> Y---------- ---------------------------------------------- <br /> m U 2e !� SAN JOAQU LOCAL. HEALTH DISTRICT Fas 21677 REY.7/76 3M <br />