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FOR OFFICE USE: `•�, OR OFFICE USE: <br /> " APPLICATION FOR SANITATION PERMIT <br /> ----- ----- --- ---------- --- --- --- �No. ---77"'-�--r�-b , <br /> (Complete in Triplicate) Permit <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 . -------- -------- ....R;CA-------------- ___-._. ::._.CENSUS TRACT.-------------- <br /> R <br /> 1 '" <br /> Owner's Name----4J ----- 13 .%�`j = - Phone -rte <br /> ' `'' <br /> Addres 7 <br /> S Cit?'- .�7 't�� -_Zi <br /> µ <br /> _ P <br /> Contractor's Name------_1-9-F -------- -------- : -----+----------------------License <br /> Installation will serve: Residence'[] Apartment House ❑ Commercial ❑ Trailer Court)K' <br /> �M hotel ❑ Other-------------=--- ;----------- <br /> s <br /> Nu�mbe� of living-,iinits:_,.__ <br /> ._Numb r-of bedrooms___/---_Garbage Grinder___.---.---Lot. Size_ _.__. --__-___- <br /> l , <br /> Water Supply: Public`Syst� and-name --- -------------------­--- ---------------------- ....................... ------------------ � -------------------Private <br /> Sapid <br /> Character of soil to a de Ha a'3aneet,: `Adobe SiFill MateriaY El l If es, Sandy Loam [PLoam ❑ <br /> P ❑ ❑ Y tYPe-------- <br /> "j t <br /> ]Plot plan, SROWwing siie-of-Lot, location of system in relation to wells, buildings, etc. must be placed on reverse side) - <br /> NEW INSTAL N., (No ptic`tank or seepage pit permitted if public sew�r�is available within 200 feet,} , ; �` ) <br /> �. \ <br /> c <br /> PACKAGE,TRI=,�TIti7Yl:NT [ SEP-TIC'TANK j ] Size___ <br /> - — -- -------Liquid Depth---'`� . '------- • <br /> i J r<3 L l i 1 <br /> Capacity- - TYPe� CS --Material ---------- ......No. ------ <br /> 1 1 c - <br /> 10 <br /> 1 Distance to nearest: Well._r(_o-f:-----:______________ _Foundation___$w � ------------Prop. Line- <br /> LEACHING LINE [ ] No. of Linesf7Z7ZFX_ _' ength cf each line___.__,___,_.. F__. Total Length S0__ `_ <br /> „.r <br /> ,. Material <br /> 'D' Box--.,/._.:._T e Filter M atetial�� X� ,�Depth Filter Nlaterial_____A?�/_____________________�__.;----------------- <br /> I`------------to nearest: Well_. _.� _:4' ` <br /> Type <br /> i - Foundation._�_JN---------------.Property Line_-----5 _E___-:--- -----------. <br /> SEEPAGE PIT !: piameter_________--- <br /> Number_..:._._ ,- X Rock Filled Yes ❑ No ❑ <br /> ] Depth_ - --_:•-------------- <br /> Water Table Depth -- ------ ------ -----------Rock Size. _ f <br /> ,0c Distance to nearest: Well_' ---- --------=--------------------'Foundation___ t---------+--------.Prop, Line---- ---------- ----------- , <br /> REPAIVADDITION (Prev. Sanitation Permit# -}-/-------- ---=-------------------------------Date------------ <br /> __-I- -------_---------------._k.) 4 i <br /> Septic TanO(Specify Requirements).._..:.------- <br /> --------------- ! <br /> — - - ---------------------------- <br /> Disposal Field (Specify Requirements).-- ---=--------- -------- -11 1 i I �r 1 <br /> ------------------------------------ <br /> --------- =--------- ------ -----.. -----------------.. - <br /> ' I = ----v----------- ----F-- <br /> (Draw existing and required addition on reverse side) i <br /> I hereby certrfy that-I have prepared this application and that the work will be done int accordance with San,;J aquin County <br /> Ordincsricef, State Laws' and Rules` and,-Regulations of the San Joaquin Local Health Aistrict. Home owner or licensed agents <br /> Sig <br /> nature certifies the.folio w[ng: <br /> "I certify thin`--the-p�erFo'rsnance of the work for which tFiis permit is is ued, I shall not employ any person .i n-such-Manner as <br /> to become lsub;ect( t ,Wo F dn' ps om ensation laws of California." <br /> Signed h , € --- -------Owner <br /> * � <br /> " --------- :-Title--------:------ --------- ------------------------ <br /> If otf er,than:owner} <br /> FOR DEPARTMENT USE ONLY <br /> ( <br /> APPLICATION ACCEPTED BY _ -- �_ -- ------------DATE.--- -- ----------------�7----------- <br /> DIVISION'! <br /> ---- -- <br /> s s <br /> DIVISION!OF LAND NOMBERl--- - ---- ----- j DATE.- ------- -I------- -------- <br /> ----------------------------------- <br /> ------- s <br /> ADDITIDKAI GMMEa T�--=- i �,t � ` - ` - - --------------------------- -- <br /> = 5 11 <br /> - -----= - , <br /> -------------------------- <br /> ------------------------------------------ -------- ------------------- - �' <br /> e ---------------- -----/--- - ----------- -------- <br /> ------- <br /> - - <br /> Final Inspection by------ , - _ Date -�(� ? <br /> EH 1324 Y T -=- ---- -- - J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 Icy. 7/76 3M <br /> J - - - ___ — cf-D, <br />