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s <br /> -FOR -d-MCE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> Date Issued_-`�.`_a 6_" <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San JoaquinLeo <br /> cal 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.... l..` '�,�... •... 4. DC ..... ......................:..CENSUS TRACT. .._�'� -.. <br /> Owner's Name.-.. _T 01 .............'---------:--------- . ----- ----------------------------------------- <br /> Address- <br /> ------------------------••-.-.--Address-- r^�--_ 1..7 -..... - Cit - -------------- ---- zi <br /> ..�..: _ _ <br /> Contractor's-MNamer--.-r...,.A r _..;_al Lice <br /> --- <br /> I <br /> _. <br /> Installation will serve; Residencel? Apartment House ❑ Commercial ❑ Trailer`Court ❑ <br /> Motel ❑ Other------- ------ - - -- ------------------------ <br /> t <br /> Number of livingunits:._ -. -----Number of bedrooms.�_....Garba e Grinde.r_--.--.-----Lot Size_-_- <br /> t�.. . g 6. ot-------- ---- ---- ----- -- - <br /> -------------Private ®" t <br /> Water Supply: Public System and name....:.. ........ .. -----------------------.--_-------•--------..--.----..._....._._ i <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Saridy 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 /> 1 ( <br /> NEW INSTAL.ATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.. . .. .... . ................ -- -= --...... <br /> 7o`/k' �r. • --- -Liquid Depth.a��----- . 1 <br /> ..No. Com - ; ......... .... <br /> CapacitY� `'-� Type ..r�...r�Material-- Compartments <br /> . <br /> Distance to nearest: Well------ -- ......... .........Foundation--Z1. "__._ - Prop. Line__..' /....... i <br /> ( ] No. of Lines .0....._ _. r� Total 'Length . <br /> ...----. <br /> Q' Box..�.......Type Filter Matetial.� ��Depth Filter Materi �................... <br /> Distance,to nearest: Well—A.4 ..._- _ Foundation. . "_ ........Property Line..... <br /> _'.--- <br /> SEEPAGE PIT ( ] Depth................Diameter_.-__.__._.._.__.._.Number__-_.._______.____._`..__.____ Rock Filled Yes E] No <br /> 1 <br /> s Water Table Depth. --------------------Rock'Siz`e_e ..... ------------------- <br /> Distance to nearest: Well.- _------•---------Foundation... .......... .........Prop. Line <br /> Y <br /> REPAIR/ADD`ITION (Prev. Sanitation Permit#_____________________ . .._.......Date_..._._:__: ----------) <br /> ._.....-.---..-.. <br /> Septic Tank (Specify Requirements) -- --... -----•. - -------------- ----------- ------ ------- <br /> Disposal Field (Specify Requirements) ....................... .......... ------------------­-------- -------------------------- ....... ------ --------- ----- ----- - <br /> r .,...__-.. ........ .................... <br /> —7— <br /> r ri <br /> -.-...�`... - ' <br /> 1111;,,,... {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 /> Ord innnces,•"State Laws-.and Rules and Regulations of Ethe San Joaquin Local Health District. Home owner or licensed agents <br /> t <br /> signature certifies the Following: , <br /> "I 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 11 ensation laws of California." <br /> Signed--- - ....Owner <br /> By------------ ..........:Title_-------- -- -------- --------------- .. --------- ---------------- <br /> (if other than owner) <br /> 1 FO DEPARTMENT USE ONLY <br /> ...---_DATE <br /> APPLICATION ACCEPTED BY.;•-- --.... ... _ G t <br /> DIVISION OF LAND NUMBER.-_........................... ..................... ': DATE.. = -----`----.---t..-- ------ ---- <br /> ADDITIONAL COMMENTS------------- ------------------------------------ ----------- ------------ ------- ......_...-- <br /> ----------- --------------- -------- ---- - --------- -- ------------ ----- ---------------- <br /> .............._ .-------------------- - .---- -•---------- <br /> Final Inspection by------------------------ ---- . -------•...._Date..._... . ............. <br /> -- .. .. _.. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r $S 21677 REV. 7/76 3M <br /> I �� <br />