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r FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------- -------------- - b <br /> (Complete in Triplicate) r Permit�No.".-;.77 ___ <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.--- CENSUS TRACT. <br /> Owner's Name-•- - -t7d--- a1 -_:`g!:�3t------------------------------- -- ---- --- --- Phone-----------------------..-:-----•...... <br /> Address.---": / - - ----------/ --------City ----------- <br /> ------------Zip ------------------------ <br /> `Contractor's Name". /�~ `/[-r - - License #_ _�l�S.- � Phone__ frs5----------------------- <br /> Installation serve �Residence_� ;Apartment Housed Commercial ❑ Trailer Court El <br /> Mote <br /> Number of living units: -------Number of edroom ---e ----Garbage Grinder".#" � <br /> Lot Size 1 ----- ------------------ ----------- <br /> J <br /> n; <br /> Water Supply: Public System and.name' " - ._--------------- ------------------------------ --------------------------------Private <br /> Character of soil to a depth-of€Yfeet: Sand ❑ Silt❑ C-la.y ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe WFill Mater;aG___----__-_. #yes, type______:___..___.- ,_._.:.- "--:� <br /> (Plot-plan, showing size of lot, location of system in relation to wells, buildings,tetc. must be placed on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pitpermitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT w <br /> [ l SEPTIC TANK ` . ------- ------------ -----------Liquid Depth.------------------------- <br /> 1 <br /> UV Type Compartments 0A, <br /> -r Capacity T P,14,1 Material , <br /> / i- dation__,._ ��__;,,._ Prop. Line...5_l ----------- <br /> ---------� <br /> i <br /> Distance to nearest: Well :". __ __��"-.""""""-""""----____.Poon <br /> LEACHING LINE [ N'o of E irie3------ Length of each line_ u Total Length.-- ---f '___----------------- <br /> 'D' <br /> __ ____-------'D' Box -f..."Type Filter Material_5'�7,�jf?4 -..Depth ; ilter1Material__--------e-I* -.---_ _--_--_-____._____________ <br /> Distance to nearest: Well----- Q- ------ Foundation_-- d `-------------Property Line__=._�__5_---___.--_-_------"- <br /> SEEPAGE PIT [� Depth"_ -- f_- Rock Filled Yes X' No❑ <br /> Distance°to nearest: 1Nel'I. - --Z�- ------- ---------------Four;Rock Size--- -1 �-------------------- - -- ---- <br /> Water Table.Depth - - <br /> / _ <br /> .. .; � - ;- -- .'dation.-----��4-�-- - Prop. Line--��-----------------�� . <br /> REPAIR/ADDITION (Prev: Sanitation Permit#---------------------------------------------------Date------------ ------:--------------------"-"--) r <br /> Se otic Tank (Specify.Requirements) <br /> Disposal Field (Specify Requirements)------- -------------- -------- --=-------------- ----- ---- <br /> -------------------------------------------------------------------------------- <br /> ---- + <br /> -------------------------° ------------------------------------=---}---------------------------- <br /> -------------------------------- ------------------------------------------------------------------------------- <br /> (Dr''w existing and required addition,on reverse side) <br /> 1 hereby certify that.l have-prepared have pd this application andthat the work will be-done in accordance with Son Joaquin County <br /> Ordinances, State Laws; and Rules and Regulations-of--the San Joaquin Local Health District. Home owner or licensed agents_- ,,, <br /> signature testifies the following: I <br /> "I certify that in the performance of the;work for which this permit is issued,_E shall not employ any person in such manner a$ <br /> to become su jet to Wlor man' Compensation .laws of California." <br /> i <br /> ---- -- ----------- -- <br /> ------------ Owner <br /> BY- ���` --- ---- _"....--Title f - - I <br /> ` (If other than owner) ) " <br /> ;FOR DEPARTMENT USE ONLY'- <br /> a�� f <br /> rAPPLICATlON ACCEPTED BY -------------- -------- --------------------------------DATE: - 4/! -7--------------- --- <br /> DIVISION OF LAND NUMBER. - --------------------------DATE - ---- `- ---- - ---------- --- <br /> ADDITIONALCOMMENTS-------W7 'I'�------- -- ----= fCG_±= -- --------- ----------------------- --------------- -------------------- ------ <br /> i <br /> --- --------------------------------- <br /> ------------------------------ <br /> =-------------------=------------ '"" <br /> -------------------------- ------ -- -- -----------------------------------------------------------+ ? --------------------- ------- <br /> Final !ns ection•b ------------------"Date._.-- -- -"- - -- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV, 7/76 3M { <br />