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FOR OFFICE USE: FOR OFFICE USE: <br /> 'APPLICATION FOR SANITATION PERMIT <br /> erm7J 9 <br /> (Complete in Triplicate) No. . <br /> Pit <br /> Date Issuedr___?.-.__7,7 <br /> - ------- ;This-Permit-Expires;-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 rdinance o. 549 odd ex t'n y uI d Regulations: <br /> _ . ..� <br /> JOB ADDRESS/LO MION,. ... /! - --- e--epi-..-------------.CENSUS TRACT - %------------- <br /> Owner's NameQ-� 7� <br /> fiffl�� hone //f1 <br /> Address_ A <br /> - Ci <br /> Zip- � <br /> L!�.7 License tPhone_.L71 <br /> Co'ntractor's Name_ �- - ----. -�- <br /> Installation w111 serve: Residence t"Xpartment House.❑ Commercial ❑ Trailer Court,❑ <br /> Motel [j ;,Other------------ <br /> ---------- ' <br /> --- <br /> Number of living units:._:__ ` Nuri�ber.of bedroom '� g <br /> n -----Garbo e Grinder..= Lot:Size-`------- : te t . Q <br /> Wa#er Supply: Publie5yst mond name__-__!---------------------= -11 - - -------Private <br /> ... '-- <br /> Character of soil to aidep h of 3 feet�;t Sand [� .Silt(] i C y ❑ Peat ❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑} Adobe Fill Material ---------If yes, type---__-----__.--- 1------- <br /> Oil <br /> __-.__ t ( _■ <br /> Wr <br /> Bi -r <br /> (Plot plan, showing size of lot;.loca� t�%of system inf'ryelation to.wells, buildings,:etc. must be placed on everse side.) i <br /> NEW INSTALLATION [( ] SEPTIC tank�or. eepage .pit permitted if public se er i . available within 200 feet ) <br /> No;se'tic <br /> 1 ! <br /> `� <br /> PACKAGE TREATMENT TANK _ r ze,_ --_- `-- -__--__ ------------- Liquid De th;-- . -------- <br /> t , <br /> ,,//�� �C € Compartmentsr 7 <br /> Capacity.�_Z-00-_ e ___ Materia! _r7tE_ No. .__.__:____- <br /> ed i ? < <br /> ..Distance to nearestlWell...- �j __.__.- - W- ;Foundation. . - ______________Prop. Line'._ --_ <br /> y! F -- - <br /> rfti <br /> LEACHING LINE. No, of Linea- , _,_ . _Len h of�ea�ina. Total' Length _ __` -�_________._ __ <br /> i <br /> D' box--: <br /> -T-Type Filter M terial___ .__.__- __ __.Depth Filter`Materal _= � <br /> Distance to nearest: Well � -� _- ____-___--- <br /> F, undah- -_--_-- _ __. -_ ----..Property Line 4 <br /> SEEPAGE PIT V Depth��l--t Djameter�J_�.-�--__Number f' t Rock Filled Yes ❑ No <br /> = r� <br /> Water Table Depth .--.- :_ �s .__.Rock Size--/C - --� I--------------- <br /> 'd <br /> -- I <br /> /! k Distance;to nearest: Well - �. .-_ . Founddtion-_(p . _ _.Prop. Line-i`-_ _' -' <br /> I t <br /> y + - 1, -- ----� <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-.- -- '--___-:;---------------------------`=__--Date-<----,-----T------ - _ _• - 1 <br /> Septic Tank (Specify Requirements)--- =---:------- L_._= ------------------------------------------ - - <br /> ------- ----- - ----------------- <br /> p Field <br /> ( P- Y. q ---- -------------------------------------------------- <br /> -----=------------=------------- -- ---------------- <br /> ---------- <br /> r <br />� is osd Fie (Spied Re uirementsi---------------------- ------ --- -'-- -----------__-_-- � i F <br /> --------- <br /> --- -------------------------------- - ----_--- --.- -- -------------- <br /> -------------------------------- - --- - - ----------- <br /> ---- = =----------------=------- -------- ------------------- <br /> .-------------------------- <br /> .� (Draw existingand -------------------------- - -------- --- ----------------------------- <br /> �regvire' d addition on reve.rse.side)--:,� <br /> I hereby certify that I have-prepared application and that the work will be done int 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: . r <br /> "I certify'that in the pe• mance of the'wor r which is er it is issued, I shall not employ any person in such manner as <br /> to beco subj to.. o kman'l C mpen ti laws. ' ornia." <br /> I <br /> Signed--- - , .:-� <br /> BY --------- :Title �_:_ l <br /> s <br /> } <br /> \.{If other than ow r) <br /> i <br /> l �• FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_. ./'€%y *- -�� ---------------------------`--------------------- <br /> DATE �-.A--`F r -------------- <br /> DIVISION OF LAND NUMBER- ----- -------------------------- ---------- - _----------------------- ------------- -.-------DATE.:'---------- .----------- ------------------- <br /> { <br /> ADDITIONAL COMMENTS--------------------'=------------------------ = <br /> 6 <br /> -----------------------------------------------------=------ -'------------ <br /> = == = r, z----- �. _ f <br /> :-- r <br /> Final Inspection by;--- Date_.�_..-------------------------- <br /> EH <br /> ----- -- --- <br /> t <br /> EH 13 24 S N JOAQUIN LOCAL.HEALTH DISTRICT F&5 21677 REV, 7/76 3M <br />