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FOR OFFICE USE: . ��— O i FOR OFFICk USE: <br /> Y/ APPLICATION FOR SANITATION PERMIT S 7 <br /> ---------------- <br /> h (Complete in Triplicate) Permit No.... .. ------- <br /> .......................... <br /> s Date Issued--&"7-----... <br /> .....................................................:... This Permit Expires 1 Year From Date-Issued- <br /> Application is hereby made to.the San Joaquin Local Health District for a p•erroit 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 /> JOB ADDR ' <br /> ESS/LOCATION...-- ` ;- / r4,Pr� y . -... _ <br /> --.:.-..CENSUS TRACT..-._. -- ....... <br /> Owner's Nam e_..._......_ Phone . 3 .. 1 ,� ...... <br /> 2 "` lZip. � <br /> ,I <br /> Contractor's Name.....-- License -Phone.... �jZ.~ Y� <br /> Installation will serve; *Residences Apartment.House-E] Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---...."`..------------------------ ...... <br /> Number of living,units;.......1--.-Number of bedrooms=-.._ Garbage Grinder-AM..Lot Size---. a ..... ......_.: ......... . .: ..` <br /> Water Supply: Public System and name-- ............... ------------------ ----------- ---.---- ----• •- ----- .Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay❑` Peat ❑ Sandy Loam 9 Clay Loam El ; <br /> .� Hardpon4�1-_Adobe ❑ -Fill Material-. ._;If.�'yeS;-tYPe -.------ <br /> [Plot plan, showing size of lot, location of system in relation to wells buildings, etc, must be placed on reverse side.] <br /> NEW INSTAL;ATION: (No septicy,tank or seepage pit permitted,-if public sewers available within 200 feet,} <br /> L F ri <br /> PACKAGE TREATMENT [ ] SEPTIC TANKY [ ] Size":::......:: __-.- <br /> q- .. 5 Liquid Depth. <br /> �Q' � ECofmpartments-.---:_7 --.-r.-.-_--,-- <br /> --Ca acitYP -0p------TYP Z- <br /> /o ........:..P --- . GDistance to nearest: Well._.. -.10p . ...--- -- Foundation-.---- <br /> ..... <br /> LEACHING LINE [ ] No. of Lines-:7.77. d-..............Length of each line........ ---------- Total Length . f z4 ............. --.• <br /> - <br /> D' Box_.0 .--...Type Filter-Materia-l-- <br /> --;2......... ,.,,.Depth Fitter Material ------------------------------------------------- -. <br /> Distanceto nearest: W - . .Foundation------ - ----------- Property Line_ <br /> SEEPAGE PIT [ ] Depth.--;�--5.r.-Diameter..__ -3-.---..---Number..__..3_-------------------- �� Rock Filled YesE]- Noal <br /> Water Table Depth---------/Qp------- --------------- --- -----------Rock Size.....??z ....... ------•--------- <br /> Distnc to o'�nearest: Well---------.lGto--------------------------Foundation_---- s- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------- --- ------ .........Date.....---:---------------------- -.------------] <br /> Septic Tank (Specify Requirements). ! --------------------=--------- .... ------------- --------- <br /> Dispos)'Field (specify Requirements) ;...- ---------------------------- <br /> F- ---- --• - ------------------ ------------- --------•-•--------------•---------- - .......... I <br /> ..._.... ++ <br /> (Draw existing and required addition on reverse s`ide)'--"'w"— <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin u <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed ent <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." A' <br /> Signed. - ------------------ ....Owner U I <br /> By....... r.tn- ' Title !`.VlX_ Y / . . <br /> (If other than owner) <br /> FOR DEP$(RTMENTAIS,E ONLY <br /> APPLICATION ACCEPTED BY.............. . . - .- ---- -- -------------------DATE . <br /> DIVISION OF LAND NUMBER ...................... .....................................DATE ....... - --------- <br /> ADDITIONAL COMMENTS.................. ------------------- ------------------ --------------- - - -------- -- ----. <br /> --------------------- ---- .--- . ------ - .... . ------ ----------------- ----------- ----....---------------•---•--•--....... <br /> ...... <br /> -------------------=------ -•------------- ----...--- ---------------•------------- . .......:------- <br /> ...... ..... _.... <br /> - � . <br /> Final Insgecs�an by:_ -- . --' <br /> Date... - - <br /> F&S 21677 REV. 7/76 3M <br /> EH 13 24 t SAN JOAQUIN LOCAL HEALTW DISTRICT <br />