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- ` FOR-OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 77—�16 <br /> ........ -------- <br /> (Complete in Triplicate) Permit No. ...............:..... <br /> r- _ <br /> ....................I.................................... This Permit Expires I Year from Date Issued Date Issued .......-.1 :.-7i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constraci and Instal the work herein 4 <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TION , .. -�� -�']f' 0_Cj?D..• ......... ..... ......................CENSUS TRACT <br /> f .....Phone <br /> Owner's Name . . . . ..t.�... _ ..................................................... ---....._...------ <br /> Address .l 'l1. ........... CityTT/I Ar.,. /4 <br /> Contractor's Name ......................License # ........................ Phone .............................. <br /> Installation will serve: Residence[Apartment House❑ Commercial ❑Trailer Court 0 1 <br /> Motel ❑Other --------•-•-•..............•--.............. <br /> Number of living units:,,--/--.-.- Number of bedrooms _3....Garbage Grinder ............ Lot Size ..,/ ....................... <br /> Water Supply: Public System and name ..--••---------------------------------------------------- PrivdteA <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 09 Size.r�.l ......................:... Liquid. Depth .� ............. J <br /> Capacity/.Z.01)-------- ryP�71. 14N.L .... Material. No, Compartments ..Z............... <br /> `-- <br /> Distance.to nearest: Well -��.............. Foundation _��.' . <br /> ......... . __.... Prop. line __..-r <br /> ... i <br /> LEACHING EINE ,K No: of'Eines ..3---------- Length of each line.....?.0.7..._.:5........ Total Length J-1.0_--------------- <br /> 'D' Box7�...._ Type Filter Material.-,0'_,f,.........Depth ,Filter�Materiol .._ _9_ ...............................�( <br /> Distance to nearest: Welt ..SQ_--- -- Foundation -.!�q---- Property Line r.................. '� <br /> SEEP P [ I Depth -------------------- Diameter __..__........._ Number ..._..._._.._._._....._.____ Rock Filled Yes ❑ No.Q <br /> IV V5p=, <br /> Water Table Depth -•----------------•---- ........................Rock Size ----------•..................... <br /> Distance to nearest: Well ........................................Foundation .:.........,........ Prop. Line ................... <br /> REPAIR/ADDITION lPrev. Sanitation Permit# _--------------------------..............:... Date -------- ......................... <br /> Septic Tank (Specify Requirements) -------------------------------- -- ----------•--... --------------------- ..............................................I.................... <br /> Di posal Field. (Specify Requirements) -------- <br /> .. <br /> ................. --------------------------•--------- ---•----•-----•• ---._...--------------- ••••-........................------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby.,certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health_District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is Issued, l shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> SIed ----------------------------------• Owner <br /> r <br /> BY - -------------------- --- Title _..._..-- <br /> (if other than owner) - <br /> __ _ 1� FOR DEPARTMENT USE ONLY _ <br /> Y APPLICATION ACCEPTED BY -----.-----•(� S -------------- DATE -:/ 77. <br /> BUILDING PERMIT ISSUED . - ------------------------------------- ---------------DATE ... <br /> ADDITIONALCOMMENTS --- -----------------------------------------•---- -".._......_ .__. -------- ........................... <br /> ------------------- ---•------•-- .......... <br /> •--------------------------- -- -- ---------- ------- _ .....--------- .............. ----------... . ----------- ------------- ........ <br /> .-- -- ------- -------------- _ .... . .................. _. <br /> Final Inspection b Date . <br /> P y: .. .......... ......•-•---------...._...........-•-- • /� ...... - <br /> lH 13 .21 1--6 8 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8 7!t JM <br />