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{ FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> i (Complete in Triplicate) <br /> Permit No_- 77-- .y-- <br /> Date Issued-. '-}.-.-..-.--_ <br /> --------------------------- --------------- This Permit Expires 1 Year From Date Issued <br /> FApplication 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 /> ATC'JOB ADDRESS/LOCATION 7C <br /> CENSUS TRACT. <br /> -#Owner's Name--------t1A4-- --- ----- --- ------------------------------- - -- --- --Phonejl� — <br /> ��NG � CZ � -��T <br /> - -- ---------------------------- y- - -�� - - <br /> F Contractor's Name------------------------------ <br /> 0F1Zf0 -------------------------------------------License #----------- ----------------Phone--- ------------------- <br /> Installation will serve: Residence ❑ Apartment House.[:] Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------------------------------- f <br /> Number of living units:------ '---Number of bedrooms--- Grinder------------Lot Size_------------------ -—-------------------------------- <br /> ------- <br /> ----- .____._ G <br /> Water Supply: Public System and name ------- - - - -- -- PrivateF� [� 4 <br /> Character of soil to a depth ofp feet; Sand5tlt Cla Peat <br /> type:-­-, <br /> Loam ❑ Clay Loam ❑ � , <br /> ❑ Y ❑" ❑. \ <br /> Hardpan. Adobe Fill Material-__-__ __-._If es e:'-------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must-be-placed on reverse side.} <br /> �4NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] .-Size-----------------------------------------------------------Liquid Depth.------------------------- <br /> f Capacity--- --- -------------TYPe--------------------�-.-Material--------------------------No. Compartments-:--------------------------------- <br /> ' - <br /> Distance to nearest: Well-----------------------;------------------ Foundation------------------- <br /> - Prop. Line-------------------------- <br /> 1 <br /> LEACHING LINE [ } No. of Lines-----------------------------Length of each line:------ :--:--- _----_----- Total Length------------------------_--------------- <br /> D' Box------------Type Filter Material--------------------Depth Filter Material-------------------.--------'--------------------------------- <br /> l ; �. , <br /> Distance to nearest: Well----------------------------Foundation-----------------------------Property Line__________--______-----_-.----.--- <br /> FSEEPAGE PIT ( ] Depth----------------Diameter--------------------Number-------------------------------- Rock t=illed Yes F] No <br /> Water Table Depth..-:-----.•---- -------------------------- --------------Rock Size------------- ----------------------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation-------------------------.Prop. Line.-------------------------_. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---- --- ----------------------------------------Date.------------------------- ------------------ [ <br /> Septic Tank {Specify Requirements} G� --------�� ------ �` , ---------------------------------- t <br /> PDisposal Field(Specify Requirements)---------------------- --------- ---------------------------------------------------------------------------------------------------------------------- <br /> € --------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> �I (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 /> "I certify that in the performance of the work for wh' h this permit is issued, I shall not employ any person in such manner as <br /> to become subj t to W mans p at ion I of California. <br /> Signed- --- - ---------------------------Owner <br /> BY-------- -------------------- ------------------------------------------------------ ---- - <br /> -------Title-------------------- <br /> - - <br /> (If other than owner) <br /> FillFOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -� ---- = = _ --------------------------------DATE.- .— `' r ------ <br /> DIVISION OF LAND NUMBER.--------------- -----.DATE------------------------------------------------ <br /> ADDITIONAL <br /> ------------ -ADDITIONAL COMMENTS----------- ---- -------------- --------------:----------------------------------- ------------------------------------------ -- ---- ----- <br /> F,; <br /> ----------- --- ------- <br /> ------------------------------------------ <br /> ------------- -------------- ------------------------------------------------------------------------------------- <br /> '.. <br /> ------------ -I----------- <br /> -------------------- - ---- -- --- ----- <br /> F Final Inspection by - ------------- ---- � �� - ----- ------------Date 7 <br /> ----- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3m <br />