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FOR OF <br /> 4FICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ........... --- ----..._.. -- ............. <br /> (Complete in Triplicate) Permit No...,74,'--- -�/ <br /> Date Issued..... .A. 7 <br /> ......................................................... This Permit Expires l 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 /> VCENSUS TRACT-- ---- --------- ------------ <br /> JOB ADDRESS/LOCATION..-.. 32 <br /> �.....� 1��� <br /> Owner's Name.... . ..........--- ----- --------- - --- •.....Phone. 3----2//F---- <br /> Address---------- -- - - -- - �.yd...-.r---- :.. City-. ,IIt Zip . . . <br /> Contractor's Name-------------- .7---P .................License Phone--9(4_­N&//K... ------ <br /> Installation will serve; Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other- - - ---- _--- ----------_ ------- • 11 <br /> Number of living units:-----.-/----.Number of bedrooms....a7. Garbage Grinder....--.-.---Lot Size.......... S <br /> Water Supply: Public System and name . .............................................. -............... .................... ... ----------------------------.Private' <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt 0 Clay ❑ Peat ❑ Sandy Loam[' Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. .... ....If yes, type---------------------------- <br /> (Plot <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 /> </ Sxq ---Liquid Depth—-=�-'-_---------(q <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC [� 040F <br /> � Size.... .. ..... .... ..-p- -___.....-.....------------- ---- <br /> Capacity...l. d' .--..--Type.. ... - <br /> Mater -----------Compartments.--------- -,-�- <br /> r r �, <br /> t Distance to nearest: Well...... __........... ...._- Foundation.../. . ...... ......Prop. ....... <br /> LEAGW4�1< [1-K No. of Lines ---------------------------Length of each line --.--------------------.- --- Total Length -IQ,X a- ...----- <br /> ,,. <br /> D' Box-----------.Type Filter Material-...-�..- --.-- --. epth Filter Material....-.- .........................._..........------- <br /> f �[ <br /> Distance to nearest: Well-----SZZ).r...............Foundation------;?�--------------Property Line..'a... <br /> .._- <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 /> Disposal <br /> -- ---- ---------.Disposal Field (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 toma s Compens ion laws of California." <br /> Signed - - r .... --......Owner <br /> By_.... •- ------------------------------- ................. <br /> (If other than owner) <br /> F DEPA MEW USE ONLY <br /> APPLICATION ACCEPTED BY........ ...:...... ... ..-DATE <br /> DIVISION OF LAND NUMB DATE <br /> ---------------------------------------- - -- <br /> - <br /> ADDITIONAL COMMENTS_. ...d�GC�m �p _ . <br /> - -- �.. . <br /> ---------------------- ------------ ............ ..............-.. ..................• -- ----- •---- --. ----------- - .. <br /> ------------------------- <br /> .--- ....... 7 <br /> Final Inspection b --- ------- - -- --- --------••--------------- ..... -------- -----------•--- ------Date.--.....- ! ... / ...._...---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M <br />