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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION-VOR SANITATION PERMIT <br /> �_ --- - Permit No. 727-7C? <br /> - ------- <br /> -z j_� (Complete in Triplicate) - � <br /> Date Issued___ --� i <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 Cou ty Ordinance No. 549 and existing Rules and Regulations: <br /> ..,,..._ems _.�., �..�.....�� _ ;....�. <br /> pQ �i � <br /> JOB ADDRESS/ ._CATION - U ,,Q. a --------`--- - CENSUS TRACT-- ----- ------' <br /> # Name..-- <br /> Address <br /> ------------ <br /> Owner's Name -- Phone <br /> Address--.. -- --- " ----- - --- ---- --- --- -- ---- City -__ Z i t <br /> Contractor's Nome-------- -_--- e :_--_._:License <br /> �--------Phone 3 -. t <br /> 7� G <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel .„Other r W <br /> ------------- --------------- <br /> Number of living units:.__________I:_Number.of.bedrooms ___________Garbage Grinder____:-------Lot,Size________________ _.___.______, >.- ----- <br /> s <br /> Water Supply: Public System and-name--- ----------- --- -=--Private ❑ <br /> Character of soil to a depth of 8 feet: , Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ t (_Y`► <br /> Hard plan ❑ Adobe ❑ Fill Material__.__ ......If yes, type-------------------------------- <br /> (Plot plan, showing size of lot1�location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No;'s'epYic tank'�ores e-pag'e -pit permitted if public sewer is available within 200 feet,) <br /> r Size----_: ; <br /> PACKAGE TREATMENT [ ] -tSEPTIC TANK [!] . .f . .t - Liquid Depth._ T <br /> .,_ .. Capac tY - `,' TYPe ----- :,.-Material - ' No. Compartments ----- -------------------------- <br /> ,... Dista�ce.to nearest: Well ----- ` .-.--- Foundation Prop Line--------------------- --- <br /> I <br /> LEACHING LINE; „[ ] Na. of Lines_:__,_._.._- - ,-____- Length,of each line__ dotal Length.-_ <br /> ._.�. <br /> ' ' Box -.-. _Type Filter Material•__ ._ __.Depth Filter Material_-`_-------I---.-,--_ _ ____ :--------------- <br /> D ----- <br /> Dista lnce'to neardst: Well_.- ____.___ _____-_Foundation._ ------------------------_Property Line__ ____ ____------------------- <br /> -0. <br /> ____ _________ __ <br /> SEEPAGE PIT [ ] Depth iometer_ ___________Number_-_.________.___--_---- -------- Rock Fil.led Yes ❑ No <br /> _. . <br /> - --- - <br /> - -----Rock Size: '------=-------------------------------- <br /> Wate TableDepth' <br /> Distance'to nearest_ Well. <br /> .. :ielk <br /> =, dation- <br /> Prop. )Line--,-.-------------------- <br /> REPAIR/ADDITION <br /> ------------------ <br /> REPAIR/ADD TION (Prev Sanitation Permit#-------------- -.------.Date -------------------------------------- <br /> Septic <br /> - --=--"--`-"- -------------- <br /> Septic Tank (Specify Requiremnts).-=-- ----------------- ------------------------ ------------ -------------- <br /> - <br /> Dispos I Field Specify Requirements):-----=--- - -" -------------- ------------------------ <br /> ------ <br /> --- ------` <br /> ----- - - --- -- <br /> ---------------- <br /> ------------------- <br /> e <br /> _ <br /> ---------------- <br /> (Draw existing and require 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 6econ3e subject to, o km 's- ensation laws of California." <br /> ------..:_ -- <br /> Signed_ aOwner <br /> EY ----- --- =---- ------ <br /> ----- ----:---” le . "..} ... - <br /> ._ <br /> 'Tit _ <br /> '[If other th= wner) <br /> FO EPA MENT USE 9NLY. <br /> APPLICATION ACCEPTED. T'_ _ - ------------DATE.-.-- - <br /> t DIVISION OF LAND NUMBER ---= - <br /> -•---_--- --------------- ---------------- --------------- - ---------------------- ------------ DAT <br /> - <br /> -- ------ <br /> E ----------- ------ ------------------_-- ------ <br /> --------- <br /> ADDITIONAL COMMENTS �M- --------- -------------------------- ---------------- ----------------- <br /> - -------------------- --------=-------------=----- ------ --- <br /> --- <br /> =----=- --- ---'------------------------------ ---------------------- <br /> ) ----------- -- <br /> -------------------------- ------- J• <br /> ----- <br /> '-------------------------------------------------- <br /> ---------- <br /> - - I� --------------------------------------------- ------- ------------ ' <br /> -----------------------------------------------p----- - <br /> - <br /> � - <br /> Date' <br /> ------------ <br /> 62 <br /> Fina! Inspection b _, -.--- _�.— _ v�_ �..�:-�..:. ,._ �:_ __-_ _ <br /> ----------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&5 21677 REV, 7/76 3M <br />