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6t�0 �5. -?� Pte. <br /> FOR OFFICE USE: (797 FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Cam lets in Triplicate) Permit No.__7 ----------- <br /> OO---7 M 4 11 Date Issued- <br /> ...................... ------- -------------------------- <br /> ssued_.........-__..............__.__..__.-_-__--____-.__ 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 in compliance with County Ordinance No. 549 and existing Rules-and Regulations: <br /> JOB ADDRESS/LOCATION---,f!mT-- -- - -..-- `A^�__Jr,o vlH ---R, VEY___--G[.vG__------CENSUS TRACT----------------------..-_- <br /> Owner's Name------� _ 1 G eTh- ------ t9N _e_A y-o Phone <br /> -- ----------------------------------------- --------- ------ <br /> Address-.--------34�_;?Vr-------��j E? 1c�`v----_gel------------------------------------Ci ----Zi <br /> Contractor's Name---)!F<_.9. —Thr_, -----f._SC?.!_V--------------------------------License ---------Phone__S" <br /> Installation will serve: Residence® Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------------------------------------- <br /> Number of living units:------J---------Number of bedrooms-----/-----Garbage Grinder------------Lot Size-------------------------.__._-________________________-. <br /> Water Supply: Public System and name--- _R. ____-____-_Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam W <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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth ------------------- -'d <br /> Capacity-_),A_O V-------Type- 11 1F <NtT.Mater ial----C__°Nt---------No. Compartments----------X%-------------------------Q <br /> Distance to nearest: Well-------------------------------------------Foundation----10--_ ._______-_-Prop. Line-__ ---------------------d. <br /> LEACHING LINE [ ] No. of Lines--- Q�_x �__`____.Length of each line_----.------------------------Total Length---------------------------------------- <br /> 'C;LTey Bei D' Box___.`__----Type Filter Material g4.4/ .______Depth Filter Material_ ' <br /> Distance to nearest: Well----------------------------Foundation--- -----______----.Property Line--- ------------------------------;t'7 <br /> k <br /> SEEPAGE PIT [ ] Depth----------------Diameter---------------.----Number-------------------------------- Rock Filled Yes ❑ No❑ <br /> WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ <br /> Distance to nearest: Well---------------------.-.___-__-_-__--__Foundation_-----------------------Prop. Line.___-._____________________ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#________________________...__-.______--_____._.Date_____-_-__-_______________--_--.--__-_) <br /> Septic Tank (Specify Requirements)----------------------------------------------------------------------------------- -----=-------------------------------------------------- <br /> DisposalField(Specify Requirements)---------------------- ------------------------------------------------------------------------------------- --------------------------------------- <br /> --------------------------------------------- -------- ------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> (Draw 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." <br /> Signed---- Jf�'!t� �� ----------------------------------Owner <br /> By----------- `rPt Title - <br /> fief than owner) <br /> R DEPARTME ONLY <br /> APPLICATION ACCEPTED BY_ ___ ___________________________DATE __etc -^- _ .__._ <br /> DIVISIONOF LAND NUMBER----------------- ---------------- - ------DATE----------------------------------------------- <br /> ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------------------------------------- --------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------ --- ----- ---- ------- <br /> Final Inspection by:--------- - -- ---- -- ---- ------- - - -------Date - 7 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV.* <br />