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i <br /> • qi <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> Y APPLICATION FOR SANITATtON�PERMIT <br /> ..."-......-------------------------_. Permit No.7K..11 6,5— ' <br /> (Complete in Triplicate) <br /> --------------------------- - -• ---------....----------- ;.. <br /> I ,::; Date lssued.f�.�y`2r ; <br /> ......................................................... t 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 incompliance with County Ordinance No. 549 and existing.Rules and Regulations: <br /> JOB ADDRESS/LOCATION.... 11 ......._ <br /> ' <br /> / ----------CENSUS TRACT..----- <br /> Addresss� ..�y.. a Co � t e/We C� iPhore.. <br /> to."4 <br /> Owner's Name. <br /> caUJ ; __ZIP.. <br /> ... - .Ch city---• ?2! .. <br /> Lcense# Z (_Phone-..Name------- --`"" _ J � <br /> Installation will serve: ResidenceL� Apartment House [ICommercial E] Trailer Court F]Motel ❑ Other-- --- - --------- ----------------------- <br /> Number of living units:....... .....Number of bedrooms-....Garbage Grinder.1!0.1ot Size......P®.. `.0.x--- i. ......... .---- <br /> Water Supply: Public System and name-- ----------------- ---------- - ---- {.... - --.Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ <br /> I` =_Hardpan.❑,Adobe [] Fill-Material,- ...: -...If,yes,_type-_--------------I .......w...... <br /> — � <br /> {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] a <br /> NEW INSTALLATION. (No septic tank or seepage pit permitted if /public sewer is available within 200 feet,} f <br /> TIC TANK [ jL Size...:.." -.(P.)(�. --------- Liquid Depth..:: ---....----k PACKAGE TREATMENT �r /� nn. ,- yy, <br /> Capacity.... IGf-Iype..�2e_ Material"_'.•=4a �hf�o. Compartments.----.:-�_-_-- ...... <br /> Distance to nearest: Well'.....--, -f Q--------------------Foundation----�.a... ..-- - Prop. Llne.... -----------.. <br /> ., e ., <br /> LEACHING LINE .. [ ] No. of Lines...........-------:..".. Length of each line.....`�.-'�_�--..:s-Total Length ..------�ZU� ------------------- <br /> � 6� <br /> 'D` Box_/... ._T a Filter Material... .Depth Filter Material-------- _Q .......- <br /> yp �----- •- - <br /> - .. .. <br /> �. <br /> Distance'to nearest: Well .".__. :.-'...Foundation....._". "'""^`-------- -Property Line-. ..-.. <br /> SEEPAGE PIT : [ ] Depth_.rs`Z.S....Diameter...---�L='�--.Number._.....-'_`=...��k------ �r Rock Filled Yes ❑ No <br /> Water Table Depth--------------�d------- � --- .....Rock Size � ----------- -- � <br /> �` -..--.. . ., <br /> Distance to nearest: Well.----7.- ---- ------ ----------Foundations--.7. ........Prop. Line....... <br /> -----------_..-"---- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....:-_--.-.------------ --"------<--- ------Date..........-------------------------------------} <br /> r Septic Tank (Specify Requirements).................... - <br /> Disposal Field (Specify Requirements)'.......-- _ - ...... ---------------- ...... ---- <br /> r # a <br /> --------------------- - ..................... <br /> -- ----------------------- ----- -------- <br /> ................................................................................................................. ------_ - ---- ..-..-=y�*.-._......"---.............----------------..-..----- <br /> - -- ---(Draw existing and required addition on'reverse side)- —n- <br /> I hereby certify that I have prepared this application and that the-W'ork will be done in accordance with San Joaquin County <br /> i- Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local,Heo lth District. Home owner or licensed agents <br /> signature certifies the following: ) t x <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 /> } " <br /> to become subject to Workman's Compensation laws of California." <br /> Signed. :=---=-.�—_:�.-�-�.....�.�..:�:�,�.-�..--_.Owger•��e� �•,,..,�,...,�..,._- , <br /> ----yp ` <br /> x <br /> -------------- ----Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----_------ - - ------- -.--DATE --- ----------_-- -- <br /> -- ---. <br /> DIVISION OF LAND NUMBER--- -------- --------------- -- - DATE--------------- ---- <br /> ADDITIONAL COMMENTS------- -- ------------ ----------------------------------------------- ------- ------.. <br /> - ------------------------ ------••------- ------- ----- -- ----- <br /> i ..---------- •- ................. <br /> -------- ---------------------------------------- = y <br /> Date o <br /> Final Inspection b - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />