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FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 77-777 <br /> ---- -- ... - .......................................... <br /> -------------------- -_.........._ (Complete in Triplicate) Permit No...-- _--------------- <br /> --------------- --- ---------------------------- 7 >2 -77 <br /> Date Issued.._..--------------- <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 /> jyjyTa i a>-, ;r <br /> CENSUS TRACT. <br /> _.___..__._ .... <br /> _.._._ <br /> --_..JOB ADDRESS/LOCATION......__.] i -- _T <br /> y � .__Phone. <br /> Owner's Name_ - . . <br /> 9Yxa rrr -teeR� - city fi1ye)-c Zip ..._.._.._..._..Address . _.....--e -- --- -- <br /> SOS <br /> Contractor's Name.-- T <br /> < <br /> License# b.. `,58(-------Phone,.st--------- ­---------- <br /> Installation <br /> _y - - --- <br /> Installation will serve: Residences X! Apartment House,❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other........ 4 <br /> Number of living units:___. /� AeYC S <br /> Number of bedrooms-... ._.._Garbs e Grir�der.,�.1F,_...Lot Size.__.._ _ -------------- -- <br /> _ 9 <br /> Water Supply: Public System and name__ ................... -------------------------------------------- -F------------------ ...... --------Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam L-J Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material_ _ ..If yes,type........ ....... _ �_ <br /> - ----- ----- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc-Fu st be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ,. ----1 �� <br /> PACKAGE TREATMENT [ } SEPTIC TANK ( ] Size__...-_.._..__:_'__~. .�--- ---•-}•---------------- --Liquid Depth_.-.____._________..___.. <br /> Capocity_ k0o....___.TYPe .&9-41fT--Material_.�--!T_._..........No. Compartments.--- -=z-------------------- <br /> Distance to nearest: Well------------------------- Foundation----10. ..-- --------Prop. Line ......... <br /> LEACHING LINE [ } No, of Lines..___._. . �V .r <br /> g _.._______.__..._ <br /> ....... ..... g .. g � Totcl LeFelI __ <br /> 'D' BoxType Filter Materia ,AOG.��_f_Depth FiY}ter <br /> Materia �------------- -'------------------------- <br /> Distance to nearest: Well.............. ..............Property Line— -----------.•.- - - - <br /> i <br /> SEEPAGE PIT [ ] Depth........__.. .Diam6ter NJ.. Rock Filled Yes ❑ No <br /> Water Table D --- ------------------------- <br /> ) <br /> Septic Tank (Specify Requirements)._____... �-4h-3 -!--------------1.---1-0. --�� <br /> ------ ---------� <br /> Disposal Field (Specify Requirements).... - `+ <br /> F `- ,� - -------------- <br /> r <br /> ------------ <br /> -----.- ,�. ...--- --------- .�. <br /> N <br /> I hereby certify that I have prepared thi I, accordance with San Joaquin County <br /> Ordinances, State laws, and Rules ai District. Home owner or licensed agents <br /> signature testifies the following: i� I f <br /> "I certify that in the performance of th, I employ any person in such manner as <br /> to become subject to Workman's Com <br /> Signed . r R.v i hvni -e $. <br /> 9 --------------- -� ............ <br /> By........, �.0 - : ....... ............ . ....... <br /> - -- ----- --- -- ---- -------- <br /> 0 er than.owrierN <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _._ ..................................DATE....... __`--'.�.f"' ----------- <br /> ......... ---•---------........_..._.....DATE_......._._.-----._.......-- --- -------------- <br /> DIVISION OF LAND NUMBER.....ADDITIONAL COMMENTS----=--------- - ------------ ----------------------- ----- ......................................... ............................................................ <br /> -.- .. _. +r- .- •�. •........ ............_...._-._..__................._�.... _.____ __. ..___..____._.w"� .......... <br /> ...........................................................................6­­­.........................................................................................................•-.._.................. <br /> ._..... ..........••. ..- <br /> Final Inspection by:............ --------------- -------------Date.--- �1�-:.. � . ......_... <br /> EH 13 24 SAN JOAQUIN'LOCAL HEALTH DISTRICT FGS 21677 REV.7/76 3M <br />