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i x. <br /> I <br /> FOR eOFFICE USE: `FOR OFFICE USE: <br /> APPLICAT40N W- R-:SANITATION PERMIT <br /> (Complete in Triplicate) Permit �c_�� <br /> __....---•-----•------------- --------------- ----------- <br /> .............................. ........ This Permit Expires 1 Year From Date Issued Date issued S.'"��_:'.?.✓. <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described.a <br /> j This application is made in compliance with County Ordinance No. 549 and existing Rules and Regu�ions: (' <br /> JOB ADDRESS/LOCATION._....... <br /> ._ <br /> -� x ��"�ENSUS TRACT---- ------------ --------- <br /> Owner's Name.--- --��...�� <br /> Address_. �dZ? <br /> .----- City----� A4 ...--.... .Zip------ --- --------- <br /> Contractor's Name---..... -e��.i. L-6 ..__..-.... ..:. License # _ J� Phone_------------- <br /> i <br /> I Installation will serve: Residences Apartment House ❑ .Commercial ❑ Trailer Court C] ." <br /> Motel ❑ Other..... -------- - - --------•----------- Z -41 <br /> Number of living units:--__. .- `- Number of bedrooms_.:___ ..Garbage Grinder-__-:_-.-._Lot Size__..... _ <br /> >. <br /> Water Supply: Public System and name,........ ._--- -Private <br /> Character of soil to a depth of 3 feet: `.Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam „ <br /> k Hardpan ❑ Adobe ❑ Fill Material.. .... ....lf yes, type _.............. <br /> i. [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be place on reverse side.) <br /> NEW INSTAL4ATION: {No septic tank' or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ) SEPTIC TANK Size...... .. - . - Liquid <br /> Depth----------------------- -;. <br /> i --No. Compartments..;:2_­,­.._­ <br /> Capacity.�v. �P . .,.�Type.I�.�c.�C'�'f,7�Material -- -- -----------=- - --....--- ----• I <br /> /r+nn <br /> Distance to nearest:eWeIL_..''_ 2.3.__ '�^ ----....Foundation.......... . ... .. ..Prop. Line...._....--.......--.---•-.vJ <br /> i - I' <br /> LEACHING LINE [ J. No. of Lines _ .. :'_--�> - - F-_ Length .of each line._.__0�'.. Total'Length ... �&.. �_.---.-� <br /> •� 4 f i/' - <br /> D' Box_ �......_Type.Fllter Mat4_61_��4/apepth Filter Material......... �y ! <br /> Distance to nearest: Wel!_ Q"o ..'...... Foundation._..__-;,57a.;777 Pr perty Line...6 ---------- -...._-SEEPAGE PIT Depth_4--------------Diame <br /> ter------------ '...-Number.: .__.--- Rock Filled Yes ❑ No Err <br /> Woterj�Table Depth.---� .._, --------------Rock Size....... - --------------._....._ <br /> Distance to nearest: Vale'll.1__.._.....`......---;I---- --------------Foundation..-------- .......-.......Prop. Line.... -.......� <br /> T J. <br /> REPAIR/ADDITION [Prev.`Sanitation Permit#..................................... .--.----_-.:-.Date.------_---__-_.. <br /> t ��*' <br /> Septic Tank (Specify Requirements) t. ....................... --------------------..........--.......................................... <br /> Disposal Field (Specify Requirements)______ ____ ____ t ` <br /> - <br /> t Y F T <br /> {Draw existing and required addition on reverse side) <br /> 1 hereby certify that I 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: k <br /> "1 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 tooWoEkn,'s Compensation laws-!of California." <br /> Signed...... , � --- --Owner <br /> By................... . -- ------Title--------- ---------- <br /> (If other than owner) <br /> F FOR DEPART ENT USE ONLY r' <br /> ----------------DATE --�j�c3a`�7�..._ <br /> APPLICATION ACCEPTED BY.f....... <br /> _,----..- <br /> DIVISION OF LAND DATE ---- { <br /> ADDITIONAL COMMENTS---------- -------- - = - = <br /> ..........................................................................................'t:..-.......--..............._.._......._........__.............._.._.._.................. ....................._.... <br /> ....................,___..__...___...:.__..-...-....._.._.._.- <br /> /Final <br /> .__.___ _._......_...._..___.___,-_.__._______._..._____.._............... _�_ ... _----. ---- - <br /> . - .. .« - <br /> Final Inspection b Date.___` <br /> r---- --------------- �•- -- �----- SCJ.-_.. ........ .......... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />