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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ...................................................... . {Complete in Triplicate} Permit No,79'_- a:.. F <br /> ..""""""""""- Date Issued./:q�If2r�..-",7 <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 O7d' ,nceNo549 and existing Rules and Regulations- <br /> le4JOB ADDRESS/LOCATI .......... _.------------- -------------- ----- ---- CENSU�/TRACT...r.......... <br /> Owner's Name. (,�./ -------------- - ---- - ------ //////hone... r. . ._.`3`� s <br /> Q Z. Cit ..zip----• .. <br /> Address fg��... �. �] c� '- -----... -- Y -.... �"' <br /> Contractor's Name...... -.......... ....... . .....License # .............. -- ..--- Phone------------_- ----------------- <br /> Installation will serve: esidence Apartment House ❑ Co mercial ❑ Trail r Court <br /> Motel ❑ Otther--------------- ----------- ---------------- <br /> Number of living units:__._.......-..Nu ber of bedraoms...� 1..,...Garbage rinder".......... ize-----..... ........._...............::........._.....- -- <br /> Private [�' <br /> Water Supply: Public System and name. -.... --------- -.Private- - / <br /> Character of soil to a depth of 3 feet; S d ❑ Silt❑ Clay Pe Sandy Loam' Clay Loam <br /> Y <br /> Hardpan ❑ Ad e ❑- Fill Material.....- f ye , tyP -----------• - <br /> (Plot plan, showing size of lot, location of syst m in relation to wells, buildin�, etc. must be laced on reverse side.) <br /> � I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avail ble withi�'2e7 df�el)th. -- /G <br /> PACKAGE TREATMENT [ } SEPTIC TANK PQ Size.-----. --------••--- ,-[---:.. a P �` <br /> Capacity / �Q ` .TYPe. !-t.C!� -- .--...Ma e,rial.CAL+-±!.l"�l..f'_..No. Compartments------=- rte----------------- <br /> ------ <br /> f <br /> Distance to nearest; Well.:...-•---. - ��U........ ... .........Founda 'on.... ...h.--.... ...Prop. Line------•----- <br /> f <br /> LEACHING LINE [ 1 No-of..Lines._.-------3--------------Len ",ach line ........V. ----------------Total Length .......... .......----------- <br /> D' Box......I:....Type Filte Material� `/' epth Fi er Material.-..---- ------- <br /> Distanceto nearest; Well----.- Q(J...'��Foundatio ........./j- --------Property Line--------------- -------------- •• <br /> �qq f, <br /> SEEPAGE Pl4urll Depth----1.4.......E4a-P e#er-jV-`----- ------Number-------- -------•-------------- Rock Filled Yes� No <br /> Water Table Depth----------------- ... .....---.......... <br /> ..... ........Rock Size.------............. ------ -- <br /> Distance to nearest: We Four}dation:-------_ ....... ......Prop. Line-------.--.-....... <br /> .----- <br /> REPA /ADDITION (Prev. Sanitation Permit -------Date } <br /> Septic Tank (Specify Requirements).- -------------- - - ----••-;--- --.•-;-----:..---'- -------- .-- -- --......--=- ---- ...-- <br /> Disposal Field (Specify Requirements)..../ -------- .............. <br /> ----------------------_.... <br /> — --- - , - - r' -4 � . ------• ------------ ------- -------------- <br /> ------------------ = -- --- ------------ •----- ----------------••---•--------- --- <br /> ( aw existing and re ired addition on reverse side) <br /> I hereby certify that I have prepared this pplication and tat the work will be done lin,accordance with San Joaquin County <br /> Ordinances, State Laws, an� Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the Irring: <br /> "I certify that in t e erfo ante of the work or whi this permit is issued, 1 shalt not employ any person in such Manner as <br /> to become to kma Comp ion• la s of California." <br /> Signed -- --------- :-.Owner <br /> Title �---- ...."-------------- -------- ---- <br /> (If other than owner) <br /> F R D ART T USE ONLY <br /> APPLICATION ACCEPTED BY----- ------ ----- DATE ... ------.. ....... ....... <br /> DIVISION OF LAND NUMBER. P/�L.- .�j`IrLI-- .....". ---------------- ---DATE _ <br /> ADDITIONAL COMMENTS. - ----•------------ ---- ---------- <br /> FinalInsp6&ion by:.----------- --------------_-- ........ -------------------------------- ...--...-•------------- .............Date------------------------.----- ------ - ---- <br /> f65 21677 REV. 7/76 3M <br /> 4 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />