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' .. <br /> FOR OFFICE USE: � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.__ L�/g __. <br /> Date Issued_-3.:-).?__12f <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 Ordinance No. 549 and existing Rules and Regulations: <br /> -- --� E <br /> JOB ADDRESS/LOCATION-_ -- CENSUS TRACT-.-_- <br /> Owner's Name -- �'�f ;-_. - ---- ----- --------------------- -- ------- --- PhoneC <br /> Address.-. <br /> .� G(1- --�-- ---- city-- --...�-.��- ----zip - �s---- <br /> j t <br /> Contractor's Name----------------- ------------------------------ 4"s _ = 1 <br /> ----- License,#----------- ----------------Phone.--------- ----- <br /> Installation will serve: Residence Apartment House.- Co merclal Trailer Court ❑ <br /> r Motel jOther---- � — <br /> Number of living units---------- ------Number.of.bedrooms-- ' arbage Grinde,r... ., <br /> _ .___;_Lot.Size_--_-__p__�--..-._- ------_,.-_.--_._________ <br /> Water Supply: Public System and name___ ______ ____ _ � _'_. _ <br /> ;4 ------ .__Private..C� <br /> -.- <br /> -. <br /> �;..��,...�- = _ - -.-.�----�-.------ --- --- <br /> Character of soil to a depth of 3 feet: Sdnd r Cl Peau❑ -San y oam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill-Material__.__:_--.Jf yes, type---------- _ x <br /> --------- -- s <br /> - q <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: �7SEPTIC <br /> Nepfic tank or seepage pit,permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT TANK [ ] f��: i f G--_-- ------!e—.0 Liquid Depth._-.�--------------- <br /> Ca <br /> ------------- , <br /> CapacityL6.--aqP---------Type - Material = ,cl= ­No., Compartments----------------------------------- <br /> -DistDistance <br /> ance to nearest: Well.'J.0,0 -/ ---------------------Foundation-f.- .'---.-------- -----Prop. Line.-------------=--.----- <br /> LEACHING LINE [ No. of Lines.`______--3 - Length of each I na..____ ---------------------Total Length __.._------2------------------------ <br /> 'D' <br /> - ----------------'D' Box-- -.---Type Filter M'aterial--------------------Depth Filter Material-------------------.--------------------------------------- <br /> -Distance to nearest: Wel l------- <br /> --------------Foundation__- Property Line----------------------------------- <br /> SEEPAGE <br /> ____________________________ ---SEEPAGE PIT [ ] `- Depth.---,__'__-.---Diameter--------------------Number---------r----_----------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable.Depth--- ------------------------------------------------------Rock Size----------------------------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation`!-----------------------Prop. Line--------------,------------� <br /> REPAIR/ADDITION [Prev. Sanitation Permit#--------- <br /> -------------------------------------------Date_---_-------_:--.---'--.--________:_ <br /> -----) N <br /> Septic Tank (Specify Requirements)---__- �. <br /> t <br /> Disposal Field (Specify Requirements)_____________ ____ __ __ <br /> F • , <br /> a <br /> z---------------------------------------------------' ---------------"---------_------------- <br /> {Draw existing and required addition on reverse side) <br /> I 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: ' <br /> "F certify that in the performance of the work #+i which this permit is issued, I shall not employ any person in such manner as <br /> to beco su ' ct to k �St n la of California." , <br /> Signed_-- Owner <br /> -- mss: x <br /> 71 <br /> By-------------- -------------=-------------- ----- ------------- - -----------------Title-----:---- ------------------------------ <br /> } <br /> (If other than owner) <br /> ` 'FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED --- DATE.----- -:-- -s <br /> - "7-��------------ ; <br /> u <br /> DIVISION OF LAND NUMBER-- --- ------ -.. ----------- ------ ---DATE- ----------------------------------------- ---- <br /> ADDITIONAL COMMENTS--- --- '=--------------------------------------------- --------------------------- <br /> ------- --------------------- ------------------------------------ --------------- -------------- ----------------------------------------=-------------------------- <br /> ------------ - ---------------- ------------ ------•-------- ------------------------------------------------------ ------- ---------------------------------------- ?-------------- --------- A <br /> --------------------------------------- -=------------------- <br /> ----------------------------------------------------------------------------- <br /> Final Inspection by;-- _� _ ----- -- -- --- - --- -------------Date----------=--- <br /> EF1 13 24 0 1 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />