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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No--------------------- <br /> --------------------- -------------------------------- -- (Complete in Triplicate) <br /> ----------------------------- <br /> ----- --------- Date Issued--��6-.7i <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 O (Hance No. 549 and existing Rules and Regulations: - <br /> �.. - — <br /> JOB ADDRESS/LOCATION... ? -t <br /> ----- ------------ CENSUS TRACT <br /> �s <br /> P.hone <br /> ----"--- -- �-------- <br /> --�--'---- <br /> Owner's Name. ----•--------- ------------------------------ <br /> 4 <br /> :1 City--------- --- ------------ <br /> Address-_ <br /> y -- --._ Phone_. ----- , <br /> -- <br /> _67{ - "License # s <br /> Contractor's Name__._._6_'Y4 ---- - �-- --" ---- <br /> Installation-will serve: Residence Apartment House.[]�ommercial Trailer Cor ❑ <br /> Motel ❑ Other----------=� - <br /> Number of living units_______________ _Number of bedroom ___-"Garbog a Grinder------ size_.___-16 • : -y:— <br /> s_.. <br /> --- <br /> Water Supply: Public System and name----=------- ------ - ------ ---- ------ - = _: =. � -------- <br /> -Private <br /> Character of soil to a depth of 3 feet:" Sand ❑ Silt❑ ••Clay.❑ Peat❑ Sandy Loam /Clay Loam ❑ <br /> Adobe Fill Material-..--•----cif yes, type----------------------------------- <br /> f / <br /> 1 Hard-�:an_ ❑ y <br /> (Plot plan, showing sizrof,lot, location of system in relation to weI)s buildings;etc"niust be placed on reverse"side:}^ �" <br /> NEW INSTALLATION: ' (No septic tank or seepage pit permitted.if public•-sewer is.available within 200 feet,) ' <br /> V11/ y J <br /> PACKAGE TREATM'ENT.'f[ "] SEPTIC_ K [Al—' - ` Size"_S_ITT--- �•+L�---- 4'!"�---------Liquid 'Depth.- -- ---- - <br /> _ C; <br /> Capaci/��DD Type i .- ComparFments = w:" <br /> _.-T e---- -r - Material =<<-} No: r <br /> I i cs <br />+. Distarice,to nearest: Well-___ _______._--------------- --- <br /> ----Foun�a�n___ --------------= Prop. Line_.` <br /> _.-.Len Length of each Tina-------__--------------- ---.Total Length.---------5-------- <br /> LEACHING LINE V.]`No. of,Lines._--=_• --:-.-_._. ---------------- <br /> g <br /> N 0 a yi/"L•, i <br /> 'D' Box-L.�V. _..T e Filter Mat��_e--------------- Depth Filter p f - <br /> Type <br /> Distance to nearest: Well-_.--_ ---- Line_ <br /> SEEPAGE PIT [ ] Depth._-------Diameter __ `. ----i�lumber___-- -`�----------- Rock Filled Yes es No [I <br /> Water Table Depth.-- L-�--- -----------------= - .Rock Size---/ -Y-�-/ . i a <br /> Distance to nearest: Well___. - ---,- :; <br /> - Foundatione/Ap -----------Prop. Line <br /> REPAIR/ADDITION (Prevr Sanitation Permit#------------------------- - <br /> -------- --'J--------.Date-..-------------- - ----------------------j <br /> Septic Tank (Specify Requirements)__."---------------------------------- <br /> -------'------------ --------- - <br /> Disposal Field (specify Requirements)___.:,__._____._____ -------------------- <br /> ` ------- ----------------------------------------- <br /> - <br /> - <br /> 1 <br /> ----- ---- --------------- •---------•-------------- - -- - ----------------------------- . <br /> _ <br /> t .. ? ---------------- - ---------------------- <br /> ---- - - <br /> - -` --•-------------------------------------- - -- <br /> IE �r (Draw existing and required addition on reverse side) <br /> I hereby certify that.l have-prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed-:--------- --- -- ---------I--------- ---- ------------'Owner <br /> I -----.Title-- <br /> I <br /> f other than:owner) <br /> FOR DEPARTMENT USE ONLY *� <br /> APPLICATIQ - - <br /> t <br /> --------DATE.. _^y <br /> N ACCEPTED BY- .•. ' ------ <br /> I ` �/ - - DATE • ------------------------------------- ---- <br /> f DIVISION OF LAND NUMBER.-- --- --- ..-- ---------------=----- <br /> a <br /> ADDITIONAL COMMENTS__. <br /> ------------------------------- <br /> ----- --------------------- ---------- ----------.-- <br /> ------ -.------ --- ---- <br /> --------- ---------- ----- z . -- ---------- - -------- <br /> - <br /> ==------------------------------------- -- <br /> Final Inspection•b ------- - ----- ----- <br /> _ � _Date --�� ----­-Ili- <br /> y'""---�".--�"- p85 21677 REV. 7/76 3M <br /> Ex 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ,,�s, <br />