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i <br /> e <br /> k <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT t <br /> • (Complete in Triplicate) <br /> r Permit No.--- <br /> ---------------- ..................... --------------- <br /> � <br /> .........•••------••----. ................... ------ This Permit Expires I Year From Date Issued 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, t <br /> This application is made.in compliance;�with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCION. 4� .-... G CENSUS TRACT. --------- ................ <br /> Owner's Name.....'- Q' P r.---.. ..d a-veni`---.. - --- ------•--.-.Phone .. ..-------------------- <br /> - -- <br /> Address _ 3 '..-_ l � _ .. itY '� til' = <br /> Contractor's Name-------s ..----License #------------------- ---- Phone...............-----------.......... <br /> Installation will serve: Residence art e t ou a CommercialE' Trailer Court ❑ <br /> Motel ❑ Other----- - -------- ---- -- ---------------- <br /> Number of living units:------1..........Number of bedrooms...13-. Garbo rinder--------_.-Lot Size-_............ .. �.--.:-.....- .......... .. <br /> Water Supply: Public System and name ` .. ........... .........................• --------••---.....----••----- - -- - -- Private ❑ i <br /> Character of soil}to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam 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.) N <br /> NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 200 feet,] <br /> SEPTIC TANK Size--- ------ --------•----.._.-..---.-...-. <br /> PACKAGE TREATMENT * ---------------Liquid Depth.........--.------. <br /> acit .._--..� <br /> l } l <br /> Ca <br /> • p Y,Lt/wD-------TypAR-Co-w Z ...Material-.C:4o*. ......No. Compartments.----.--�,,......--............... <br /> Distance to necprest: Well-:...... � . ... .. .........Foundation----�V ----...-- ...Prop, Line-- � <br /> ---- - ...... <br /> LEACHING LINE [-I No, oft Lines ....._3------------------Length of each line...--7 ----------------- g € <br /> - ------Total Length ... �/f�....................... <br /> 3'D`{Box. ...-. .Type Filter Material�Z,' r �p <br /> } ... -- ---- ------- <br /> ;i r <br /> Depth Filter Material__.--------1.�__-. _ -- ..................... <br /> i,Distance to nearest: Well..../-C9e�.-.-..-._-....Foundation--------------------------Property Line..---- --------------- <br /> � I - ❑ ❑ 1 <br /> SEEPAGE PIT [ ] �Depth.-.�.__....-..Diameter--------------------Number-.-------------------_..------ Rock Filled Yes No. <br /> Water iTable Depth----------------------------------------- ---------------Rock Size---------------------------------- -----•---- <br /> j IF ;E I <br /> t LD.iS.tdYkce to nearest;-Well------------------------------- ......Foundation-•--.-------- .- Prop. Line-----............. <br /> + <br /> REPAIR/ADDITION (Prev. Sanitation Permit <br /> t <br /> kw #r =- <br /> ---------------- <br /> -------------- ---------------Date................- ---------.-----._-- <br /> P e _ <br /> Septic I lY fqq � + ' - <br /> Disposal Feld (Specify,Requirements).........0...........• . - ---- ---------- ._.----) <br /> ---- --- -- ----------------- - ------------- <br /> ----------------- <br /> -- ------ <br /> ' � f .�•'. 2 f E l•..11.i..R" 1 <br /> -----------------------•--------_----- <br /> __--------------- •----------_----------- <br /> (Draw existing and required addition on reverse side( <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County i <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-,he work for which this permit is issued, I shall not employ any person in such manner as j <br /> to become subject-to—Wor-man's ompen-cation laws of California." <br /> a---- <br /> By.............---- ------ ........................... '----- Title.. <br /> w <br /> (If other than oner) � <br /> # FORD RT_ AE O t <br /> APPLICATION ACCEPTED BY-------- .. . <br /> .......DATE ..-. �.3 - .......... ..... <br /> DIVISION OF LAND NUMBER.--... --- -- ---....DATE.. . <br /> ADDITIONAL COMMENTS ----- .. .. ---------- --- -------- - <br /> .-- :::: ��-------------- - <br /> r <br /> -...tet --- - <br /> Final Inspection b + Date.._-..... .......... <br /> y:.................... - -- ------------------------ ---- --------- ---- .... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT &S 2167 �ti. 7/76 inn <br />