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FOR OFFICE USE: v `FOR OFFICE USE- <br /> ------ <br /> FOR SANITATION PERMIT <br /> ----- ----- ------------- Permit No _ 7�. l <br /> (Complete in Triplicate) . . .._ __.__ <br /> ----------------------------------- -------- ---- - - - <br /> This Permit Expires 1 Year From Date Issued pate Issued-/7//7-//7 <br /> Application is hereby made to the San Joaquin Local Health District for p permit to construct and Install e h ribed. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and RegulatLTD <br /> e : <br /> / ' ==_ m a..Xrlvd----------.CENSUS TRACT--------------------- :---- <br /> JOB ADDRESS/LOC ON.........//.. s------------------ --1.___-.-- __-- � <br /> Owner's Name A0 .----------s s2-,r--- Phone <br /> --- <br /> J <br /> Address. ------ -- G -- -- -------------------- .............. Ci ` '�- -----------_-Zip------- <br /> 15 <br /> Contractor's Name_._ __0------- ------- _r —_________________ License #362/' <br /> -------.Phone <br /> Installation will serve: Residence [] Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---._-.-._.___-._ <br /> Number of living units__---------------Number of bedrooms------------Garbage Grinder------------Lot Size --__.__.._._____________.____---___._.-..- <br /> Water Supply: Public System and name---------------------------------------------------------------- = _--------- :-�_ j Private ❑ <br /> Character of soil to a depth of 3 feet: Sand F] Silt E] Clay ❑ Peat ❑ Sandy Loam E] Clay Loam F] <br /> Hardpan ❑ Adobe ❑ Fill Material------------If yes, type____________________ <br />-----(Plat 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 available within 200 feet,) W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--------------------------;______________________________-_Liquid Depth--------------------------- . <br /> Capacity------- ----- -------Type-- - ----------- ---- Material--------- _ =-No. Compartments.-_._-?-------------------------- <br /> Distance to nearest: Well.------------------------------------------Foundation--------------------------Prop. Line------.---------.-------.--. T <br /> LEACHING"LINE [ ] No, of Lines-----------------------------Length of each line..____---__--.-__--._-.-._-77Total Length --------------------------------------- <br /> 'D' Box............Type Filter Material--------------------Depth Filter Material---'-------------------------------------.----------------_.-- <br /> Distance to nearest: Well_.-------------------------Foundation � -Property Line --. <br /> SEEPAGE PIT [ j Depth----------------Diameter-___.- ----------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> fWater Table Depth---------------------------------------------------------Rock Size------- ------------------------------------- <br /> = Distance to nearest: Well-------------------------------------------Foundation------------------- --.Prop. Line_--.--_-_------.-_- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date----------------------------------,{ _`_---._) <br /> Septic Tank (Specify Requirements)_._.-._____ .- —- -----4 -. <br /> / I <br /> G � � / <br /> ;Disposal Field (Specify Requirements)_.}- ---------------- ti <br /> c ---------- --- -- --------------- <br /> -------------------------------------..---.--____-__ _____________-_-.__________________.._-_.--_--.-----_-_:---___-._---.-_____________--_-_________.___.-_-..--.-..-----.-_-..-----_ -----_----_.--_.-.._-_-----_ <br /> (Draw <br /> existing and required addition on reverse side) <br /> I 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: <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." r <br /> Signed-- Owner 51 <br /> itl <br /> (If other than owner)- <br /> 1­7 <br /> wner) _-- _-- `�— ---- <br /> " FO ^ EPAR TNi NT USE ONLY <br /> APPLICATION ACCEPTED BY-----_1-_ _. -------- ---------- - ---.-------------------DATE ------- -- --._--�- <br /> DIVISION OF LAND NUMBER------------------------- -- ---- ------------- - --------------------------- -DATE---------------- <br /> --------------------------- <br /> ADDITIONAL COMMENTS.-- `0�-------?,_�-S�- :�-5------------------------------------------------------------------------------------------------ ---- ------------- ---- <br /> - --- ----------------- <br /> -- <br /> Final Inspection by:----T -- - -- - ----- --------------------------------------------- --------------------------Date �-6. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />