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v r - <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------------------- <br /> - {Corttplete in Triplicate) Permit No._�. __�� _-- <br /> --------------------------------------------------------- <br /> Date Issued-J--,3lr7f <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 ---------------------CENSUS TRACT...... --------------- ---- t <br /> Owner's Name -- -j ...A--- ----------aG?fv----- -------------- -- <br /> �A Z i ■ <br /> Address--- ---- �. W = City p---------------------------- <br /> Contractor's Name---- �1.41 _F_04--� Z�j License Phone_,F !� <br /> Installation will serve: i Residence[1] Apartment House.❑ Commercial E] Trailer Court ❑ r <br /> . .. Motel ❑ Other-------- ---==-:------------------- ----- C` i <br /> Number of living units:--..__----------Number of bedrooms __.___Garbage Grinder------------Lot.Size. ------------------------------_-----.._._..__._ <br /> Water Supply: Public System and.name----------------- =------ ------------------------------------------ . :----- __--, . :=r.�,.----------------------Private � <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ I-Clay Loam {] <br /> j Hardpan ❑ Adobe ❑ Fill Material__ ---------If yes,type------------------------i______ <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 available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-_, .- -_/-� ._ -----Liquid Depth__. _. ._-- --_- -- ) I <br /> M <br /> j Capacity-�� 6-0---ITYpe94 '57-Material------------------------- Compartments------- <br /> ---------�+ <br /> t Distance to nearest: Well-.___ --------------Foundation.... __________`-._---- -Prop. Line----------------r w. <br /> ,. . � <br /> � _----- <br /> � <br /> LEACHING LINE Lines --- Len-,Length of each line._�C ___� - Total Length.--_No. of : <br /> 'D' Box-- -._.-'.Type Filter Material_ ' epth Filter Material._____.--P _-------------------------------------_-----`. <br /> 77 <br /> d <br /> I Distance to nearest: Wel!__ITIP-----------------Foundation.J4>_-------------------Property Line_._,- G�__��-___-.__ <br /> SEEPAGE PIT Depth__`__.____._ K.Diameter.____.__..- ----Number__----------------------------- Rock Filled .Yes L] No <br /> L p - ----- ---------------------------=------ <br /> Water Table Depth '- ----Rock Size----------- -=------- -- -------------- -- <br /> Nj <br /> Distance to nearest:Nell------------------------------ - -----------Foundation } -------- --------.Prop. Line----------------------------- <br /> REPAIR/ADDITION-(Prev. <br /> - ------------------------REPAIR/ADDITION•(Prev. San itation•-P-&rmit-#---- ----=-----------------------------------------Date------------ ----=------=-------------= M <br /> Septic Tank (Specify'Requirements).%'--------- - - -- -- ------------ --- --=------F---------- -------------------------- ---------- <br /> Disposal <br /> -------Disposal Field(Specify Requirements)'___- ! § <br /> �t - -------------------------------------------------------- --- ----------- - -------- ------------------------------------------- <br /> } 1 <br /> T� ..._ k ---- c I. --------------------- - <br /> -------------------=------------� ------------=------------------- --------- - == <br /> (Draw existing and required addition on reverse side) I <br /> I hereby certify thatl have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, 6d IRules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents' <br /> signature certifies the following <br /> "I certify that in the perfo mance-of the work for which this'permit isi issued, 1 shall not employ any person in such manner as <br /> to become subjec to Workman's.,.Compensation-laws...of-California.'&, <br /> Signed-_,4�_ -a- -------- Owner . <br /> i ----Title---- ------------ L <br /> ------------------- <br /> Y-- � a <br /> jIf other than owner) <br /> FOR DNRARTMENrUSE ONLY <br /> APPLICATION ACCEPTED BY € -----------DATE <br /> DIVISION OF LAND NUMBER.-__--- ------ ------------------------- --------------------------- ATE.�w. ---=- _ <br /> ADDITIONALCOMMENTS-_....- --------------------------------------------------------_---------------------------=------------------------------------------------------- <br /> F <br /> f - '. �:_..-_i_ ��"�-�� ------------------------------- <br /> T� 4 ---------------------------------------------------- <br /> ---------- <br /> -------------------------------- --- <br /> _________________-----------------------------____..____.____.____--.---_ _. _ _---------------------_-__-------._______.___..--_ <br /> i <br /> Final Inspection - ------ <br /> ---------- -------------------------------------- --- <br /> Date `` -- - ---------- <br /> pY--------- - -`--- -- = - -- -------- ----- -- --------------------- r <br /> FN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f8S 21677 REV. 7/76 3M <br />