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FOR OFFICE USE: FOR OFFICE USE: <br /> T •�' APPLICATION FOR SANITATION PERMIET <br /> --------------------- -- ----- --------------------------- ! Permit N6--------- S"7 2 <br /> - (Complete-in Triplicate} � ------ <br /> ------------------------------------------ -- <br /> Date Issued---7 <br /> ' -----------------------------------------------___._-.-- This Permit Expires 1 Year From Date Issued <br /> r <br /> E , <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ( �- ?�r �`�' +' ? - CENSUS TRACT---- -----_ <br /> L.tl� - <br /> Owner's Name. ----'-------/VI-�!tr.--;--- Phone a <br /> - - <br /> Address ------------------------ ' --------- wL---------------- ----- Ci;Y ----- - /}���J <br /> 4' ; F <br /> Zi - <br /> P <br /> ., ------- <br /> Installation <br /> = = License # 5 . 343 Phone-- ��-.-�'�D <br /> Contractor's Name------------- <br /> ❑Apartment, House.E] Commercial ❑I Trailer Court ❑ ~ <br /> Installation will serve: Residence ' <br /> ., .. 3 . V Motel Other_---` --- _ R. _,1----------------- <br /> y -- - K,. <br /> Number of living units:__/ -----_Number of bedrooms.=__ .-.-tea age Grinder_-__==. :Lot Size._._.--------------- ------------__.------------- -- <br /> Water Supply: Public System and name-----------=------ ----- -- -- ------------------------------.---------------------------------.:---- --------------------Private <br /> t- Character of soil to a depth of 3 feet: Sand ❑, ._;Silt,O—Clay ❑4 Peat R...rSandy Loam Q .Clay Loam ❑ <br /> Hardpan 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 /> � <br /> NEW INSTALLATION: -I(No, septic tank or¢seepage" <br /> pSf perm d i <br /> if public sewer §-avafilable within 200 feet,) <br /> * ------_------=---------- Liquid Depth g - t,J <br /> PACKAGE TREATMENT ] ] . SEPTIC TANK" Size--__;___-+ --)�_ ' <br /> ti A '... � <br /> ...,..._. Capacityl-�Z!? -----=TYPe= ,'�- " Ma*ial._C.+ No. Compartments --------------------- <br /> r # <br /> Distance to nearest: Well.{:--------._ 8. :Foundatlo -----�-0-f ---------..Prop: Line--- ----- -s---,-. <br /> LEACHING LINE No. of Lines ---_Len tai of ea h line ---- ' '"Total Length.- �LQ- --------- <br /> r, <br /> D' Box--- ..Type Filter Material-_ ----_ p <br /> ---De th Filter Material-----_--� - -- ---------------- <br /> _ ___________ _ <br /> Distance<to nearest: Well-- ------ _ Foundation-----_�4- --- __.___.Property Line-. � `--------- - --- <br /> SEEPAGE PIT ( Qepth �--_.- Diameter 3:3-- Number--- --�1 � '�-�'��•� � Rock Filled�l'es.� No, <br /> l Water TableDepth_ ------ - - Rock Size. <br /> to nearest: Well-------_ -l:�'- - - _-- <br /> r . <br /> ¢ Foundation____!----�--- --. .Prop. Line- .—-------------------- <br /> Distance <br /> REPAIR AD - -- --------------- - <br /> ------ <br /> REPAIR/ADDITION (Prev Sanitation Permit#-- --==------------------- .=-.-:D.ate -----------= ] <br /> SepticTank (Specify Requirements]-----------------------t-=------------------------------ = =-------=--------- -------- ------------------ --------------- --------- -- ----------- -------- <br /> DisposalField (Specify,Requirements)------------------------- -------------------------------------------- ----------- --------------------------------- ------------------------------- <br /> ---------------------------------------- ------------------------------------------------------ <br /> ` -=-------------- --------------------: <br /> 1 --- <br /> I t <br /> =------ ------------------ - ----- - --- <br /> --------------------------------------- <br /> (Draw existing and required ciddition.on reverse side) <br /> hereby certify that I have prepared.this application 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: T <br /> i <br /> "I certify that in the perforrrianie of'the work for which this -permit"is issued;-! shall not employ any person in such manner as <br /> to become subject to..Workman's,Compensation,laws. of California.:' <br /> Signed- -------------- --- -Owner <br /> -- ----.---- <br /> - <br /> ----- Title---- <br /> n(lf'other thas <br /> owner] } <br /> . .......-. FOR DEPARTMENT USE NLY <br /> APPLICATION ACCEPTED BY- DATE.___-_7 { f-------7- <br /> ---.-DATE = - <br /> DIVISION OF LAND NUMBER.------- -----=-------------------------- y- <br /> ADDITIONALCOMMENTS-------------------------------------------------------------- ---- --------------------------- ----------------- ------------------------- ------ <br /> -- ----------------------------------------- --- --------- ----------- ------------- ------------ -- -------:---------------------------------------------- <br /> ; -- <br /> ----------------------------------- <br /> ------------------- --------------------------- ----------- ----_--- ----------------- --------------------------- ---- --- <br /> ----- ------------------ ------------------------- Y-r"` ---------------------- -------- ---- - j -------- <br /> Final Inspection b " = = Date=- }. . <br /> !.- . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/76 3M <br />