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FOR .OFFICE USE: <br /> APPLICATION FOR SANITATION PERMITFOR OFFICE USE: <br /> ------------ - ------------ <br /> (Complete in Triplicate) Permit No. S=-.17 <br /> --------------------------------------------------------- <br /> Date Issued-L�-l/:7.r <br /> -----------------------------.-.-------------.----------- This Permit Expires I,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 ismadein compliance with County Ordinance No. 549 and existing Rules and Regulations_ <br /> JOB ADDRESS/LOCATION----------- <br /> .- ---- -- -- -- - - ------- _ CENSUS TRA ''" �- ----- ' <br /> 7� / ! <br /> Owner's Name '-------- -- - ?k -------- ----- - --" ---- . Phone - 4 - -- <br /> -- � `roc+ <br /> Cite Zi <br /> Address------ -- - --- --------- - -`--- -----------------------.----- -- - ----- ------------- Y----- _ p---- <br /> Contractor's Name___ -. �../ ---- --- ------------- -.-License #-- � <br /> -- ------------------------ <br /> Installation will serve: Residence ❑ Apartment House Com is ❑ Trailer Court ❑ r <br /> e Motel ❑ Other--- � ... . . <br /> Number of living units:..-< .-----Number of bedrooms_f_------Garbage Grinder----- -----Lot Size__=_ .t----------------------------=--- <br /> Water Supply: Public System and name ---------------------------------- ------ --------------------- ------------------------ ------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat [] Sandy Loam [a?—Clay Loam ❑ <br /> Hardpan ❑7 Adobe E]`-Fill Material._.._`.-..--If yes, type---;.___----------------------- <br /> " I <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or'seepage pit permitted if public sewer is availaSle within 200 feet,] f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Sixe---- q p <br /> 2V <br /> PACKAGE Liquid De th. <br /> t /� <br /> Capacity./��_---Type._R -----Material--(.:--o;-O-'----------No. Compartments---------r------------------- <br /> Distance to nearest:.Well.--._-. .: m:____- _------.----Foundation__- -�-I ___._._...Prop. Line___/P® f <br /> i �`-.Len Length of each line>.- _ tea ----------------.Total Length ------------------------ <br /> LEACHING LINE [� Na. of Lines-___---_�__-_----___.__ - g . g ------------------------------------- <br /> - <br /> D' Box------------Type Filter Material_ k �-��'� er Material...12--------------------------------------------------------- <br /> Depth. <br /> r _Foundation_. <br /> Filt <br />. � Distance to nearest: Well--- <br /> ------------------------.Property Line----------------------------------- <br /> ber"--': <br /> .SCJumber---'------_ .1, - - - -- <br /> SfE'F �'PhT [ ] Depth.- --__j--- i / Rock Filled Yes No ❑ <br /> - _,1 . / �* --- .R-ck ize� / <br /> Water TableiiDepth `-= <br /> Distance to <br /> . Foundation ------------------ <br /> REPAIR/ADDITION --- __.Prop. IL- <br /> ine._ <br /> - <br /> (Prev. Sanitation Permit#..•----'- ----------------- <br /> ' ---------------=-------Date-----------------------=-4 <br /> ---------------------- <br /> Septic Tank (Specify Requirements -_ ---------- --- ------ ------------ -------- ---------------------=--- <br /> Disposal Field (Specify Requirements)------ -- ------ f- -------------------------- --``-- - <br /> Z, t <br /> ------------ ------ ------ _--- ------------ - ! ------------------------------------------- ---.---- -- <br /> --------------- ------------------------------------------ _ -------- -- --- -- ----------------------- -- _ <br /> ! <br /> (Draw existing and'.required addifiion-on reverse side)Ui ' <br /> I hereby certify that 1 have prepared-this-app lication and-that the iwork-will-be-done-•in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules•and Regulations of the San Joaquin Local Health District Homeowner or licensed agents <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 Work n's Compensation laws of California." <br /> Signed ------- -- - - Owner <br /> tcf! -----------------------------------Title--- =------------- <br /> (If other than owner) ` fi <br /> d FOR DEPARTMENT USE ONLY T <br /> APPLICATION ACCEPTED BY C, --------------------------------- -------------------DATE.-L0- 'r— ------------------------- <br /> DIVISION OF LAND NUMBER...------ - ------------------------------- ----------------------DATE------------------- . ----------- <br /> ADDITIONALCOMMENTS-------------------------,-------- ------------------------.------ ------------------------------------------------------------------------------------------- ---- - - <br /> ---------------------------------------------------------------------------- - --------------------- -----•-------- -----------------------•--------- -------------------------------- <br /> ------ - --- - -- - --------------------------------=------------------I-------- <br /> ' <br /> Final Inspection by ` = Date <br /> -- - ---- ------ --=------ _.. <br /> EH i3 sa SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />