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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATIQN PERMIT <br /> (Complete in Triplicate) Permit No.. ........... ....... ! <br /> ---------- --- - Date Issued _2-�. 7 7 <br /> r ....... <br /> -----------------------------------------_.-......._- This Permit Expires 1 Year_From Date Issued <br /> _Application is hereby made to the San Joaquin Local Health District for a permit toAc' bnstruct and install the work herein described. <br /> This application is made in compliance with County Ordinance No.549 and existing Rules and Regulations:. <br /> i� f <br /> JOB ADDRESS/LOCATION. �7.Zr.l.-- . _-6!d_-- ..41fL __ CENSUS TRACT... <br /> / =----•-----••................................. dl ._. <br /> Owner's Name.a/4Lje.t!L .........Phone....7.r4_7_-5 �� <br /> Address....L7._. ---- ------- --------------------------City. --•WQ<_q ._.• ................. <br /> Contractor's Name_.�a �_.� -- ,�..........4'....r_.1-.------.-.--_License #... a.S7.. /-------Phone---3b,1r-3F3j-.-.- <br /> Installation will serve: Residence ❑ Apartment-,Hou ~.❑ Commercial FOP'frailer Court ❑ t <br /> Motel ❑ Otlferr <br /> Number of living units:................Number of bed room s..._L5'__.Ga'rba e Grinder.^...`Lot Size _ .. ......_ ' <br /> ....._..... ••... <br /> Water Supply: Public System and name----------------------- _ - ..... ........... -------------- - ............. .... .. ...... -Private <br /> f <br /> Character of soil to a depth of 3 feet: '1Sand ❑ Silt ET/ Clay Vii_. Peat❑ Sandy Loam ❑ Clay Loam ($_� <br /> t Hardpan ❑ Adobe❑ Fill Material._ 1 If•yes,type................................. <br /> (Plot plan, showing size of lot, location of sys#em in relation to'wellsfbuildings, etc must be placed on reverse side.) 1 <br /> NEW INSTALLATION: (No septic tank,or seepage-fpit permitted�if public sewer is available within 200 feet,) ` <br /> PACKAGE TREATMENT [ } SEPTIC'1ANfK_[..] ' <br /> -----� • <br /> { Liquid Depth.................•-------' <br /> Ca aCit ....T ..._..� � <br /> ..Material.._ . �_No. Compartments................... <br /> Distance to nearest:.We1I..............:4................../.Foundation_..._._-.-.._._.-__...__._Prop. Line_.__....:._____.__-....'.. <br /> LEACHING LINE No. of Lines_.--.v _.._.--__._ g g <br /> ""I Len th•of ebch line.--------- ------------ -------Total Length <br /> D' Box............Type Filter J1Aaterial \_ Depth Filter Material... 4 <br /> ■a Di stance to nearestt'WelI.[_...y.M ........... Foundation.._=-------------------------Property Line.._.._............................. <br /> SEEPAGE PIT :[ ] Depth.................Diamater--------.---------- m)ier................. Rock Filled •Yes [] No E] <br /> WaterTable Depth---•---.• '•-.......................... ,------........Rock Size............................................. <br /> _ A v ' <br /> to nearest: Well"....-...�'._. '"'------_-_-----I_Foundation_........................Prop_ Line--_-__..__--_.__---------- <br /> Distance <br /> REPAIR/ADDITION (Prev.,Sanitation Permit*__... � ------------------------------Date__._.................................. <br /> .._.....J <br /> Septic Tank (Specify Requirements)_:.__-_..._..:.:..!.� r ` ! ................................................... -� <br /> ---- -----••-- <br /> � ------:� ------/----------- 1..:.. _. ^� n, �,�� <br /> Disposal Fiel (Specify.Requirements)................ ' ;,...LAeL � `� - 1i<---------�`-/�'^� ...._..• - : <br /> _....az?�........ .:.. --•----•-------. ----- ------.:. ---- ------------------------------- -----:- =--- -------------......................- ------ <br /> ---------- -------------------- i <br /> (Draw existing and required addition on reverse side) ' <br /> I hereby certify that I-have prepared this applicatlon 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: fl <br /> "1 certify that in the performance of'the walk for which this permit is issued, I shall not employ any person in such manner as <br /> to become 'subiect to. rkm n's. Compensation laws of California." <br /> Signed.-.. =------------=-----=--------------Owner <br /> - <br /> By........ .. _...,....... � _--Titie_Ak� -- ---D . <br /> > <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY- <br /> APPLICATION ACCEPTED BY------ - _ ............................. ................. ......................DATE.. ............................ <br /> Y <br /> DIVISION OF LAND NUMBER .-_.................. .. .............. ............ ......-=--------.............--•----- ....._DATE_------------------------_- --..__.._:._. <br /> DDITIONAL COMMENTS........... <br /> ------. .- -- --- -- ----- -- ------------------:..-- ------......_... ......-----•------. i <br /> .....................................................•_...................-.............................._--------.--_---..__......-----•-----------------................__----_--..__.............._..I.. <br /> ----------------------------------------- ..............................___..................._........................ ... ............... ----------------------------------------------------- <br /> ....._...-_•............. ...... ..------------------------------•-----•-._...---------.................- .................................- Y <br /> ion by: / --.-•-------•-------=-------------==------ i`..... Date.... -IL__...._ -.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.7/76 3M <br />