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4 °FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � _�/ <br /> Permit No..-"- 7 ( <br /> (Complete,in Triplicate) *c <br /> --------------------------------.......... .............. Date IssuedsZC_-79 <br /> This Permit Expires I 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 incompliance with County Ordynaa No. 549 and existing Rules and Regulations: <br /> } <br /> JOB ADDRESS/LOCATI N"--�_-��S_.----,1../_'-. ... - .- .- ....--..CENSUS TRACT.............................. <br /> - - - i <br /> Owner's.Name.--.. ...... <br /> - - <br /> � �! <br /> .. .. <br /> - . Zip = <br /> Address-...- ..-_- �--- ---- -- "- ----------- ----"----- - City- se o <br /> --- Licen ....... - <br /> Contractor's Name---" - - <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-. ----.."..---- ---- ------------••--..; , r <br /> •. ...... <br /> ( <br /> Number- of living units:........--Number of bedrooms-. -. Garbage Grinder-.-..:--.-.-Lot Size---.3 �-. <br /> Water Supply: Public System and name---------------- <br /> _ . ----................... ---------Private R 9 <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy LoamCla Loam <br /> Hardpan SZ Adobe ❑ Fill Material.-...- -...if yes, type---------------------------- t <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side_.) LI <br /> NEW INSTALLATION. (No "septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT ( ] SEPTIC TANK Pc] Size.-- .- <br /> ,�` Liquid Depth.-IV------ <br /> 1 -. Material=- -- �.--=---:No.-Compartments-----..t�--"-----•", <br /> CapacifY-f--a:Q0--------Type- -- h�, <br /> Foundotion-./ - ------ Prop. Line-- <br /> Distance to nearest: Well----.-��- ..... - •--- p, <br /> i <br /> LEACHING LINE No. of Lines- ----- ------------------Length of each line-YG..--��.---�i��. ..Total Length . --- ---- <br /> .r <br /> • -----------�--Pro Property Line-... -•--- ---------- ............._ <br /> 4 'D' Box...✓....Type Filter Materia[S "-- Depth Filter Material--.--/19 .- <br /> Distance to nearest: Well---3 -.----,.------..Foundation----�---•. p y O <br /> ...Number----•- .... <br /> 10 Rock Filled YesXr No❑ <br /> E PIT ( Depth.. ,�.---Diameter---------------- <br /> t/ �r <br /> - Rock'Size.-_.. •--•------- <br /> SEEPAGE <br /> Water Table Depth----.--� ....-_. - <br /> � ..--.Pro Line.--:•T- ---- <br /> --..Foundation--- <br /> --------" <br />� Distance #o nearest: Well---.�-�-�-- "-�----- �------ • <br /> I` .......Date------------------ -----) <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------••---•---------------- ----------" <br /> 4 -------•----- <br /> 4 Septic Tank (Specify Requirements)------ ----------------- ----•--- = -- •------- ....._. <br /> Disposal Field (Specify Requirementsf-.... ......... ---- ' <br /> .-....--- <br /> ---------- ----_............. •-- - ------------ ............... ....-i <br /> r ---------".-"---------------------- ----"" -.--.--.---..--. ..--..---.---------- <br /> ---------------_.--.-------"--------------.-....-----......---"-....-.----------------- .-.-°.--..-.--. <br /> (Draw existing and required addition on rev <br /> erse side) <br /> k I hereby certify that I have prepared this application and that the work.%4ill 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 /> k <br /> ") certify that in the performance of the work.for-which this permit is issued, I shall net employ any person in such manner as <br /> to become subje o Workman's ompensation laws of California." <br /> �.-r --------------Owner <br /> Signed--------- ----� --- •--� -• •---- - <br /> .. � <br /> Title..- ------------- ------ <br /> (If other than owner) . <br /> PO DEPARTMENT USE ONLY <br /> o-�' 7- - ATE "" <br /> APPLICATION ACCEPTED BY-..---- . - - - - <br /> -- <br /> .. <br /> ATE. --. ------------- <br /> ---------------------- <br /> DIVISION <br /> ----- - <br /> DIVISION OF LAND NUMBER.- ---.-- <br /> ADDITIONAL COMMENTS_-."- ------ ----"- <br /> ------------------------ -------------•--- <br /> r-.. --- - <br /> -•-•---...-•--•--••-•...................•-- -- ----- ---Date.---• -•--�"-r- - ..."--- -- . ._._.. <br /> Final Inspection b - ---- <br /> 7F&S 21677 REV. 7/76 3M <br /> EH l3 24 SAN 1 IAQLIIN OCAL HEALTH DISTRICT , <br /> i �� <br />