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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No._-7-7'------------ <br /> ------------------------------------ <br /> 7,FZ <br /> I <br /> ` -- y <br /> "'------"-" ---- ---- - ----- -------- This Permit Expires 1 Year From Date Issued <br /> Date Issued-_. <br /> ,3 <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 /> 00 7 <br /> JOB ADDRESS/LOCATION/�aY -__.- 1, � <br /> N <br /> --------CE .SUS .TRACT <br /> Owner's Name ---- ' = <br /> - y� <br /> _ <br /> ------------ a------ <br /> -Address <br /> :---------- -- - - ------------ ------- -----CityZi <br /> -"--Contractor's Nam ------------- <br /> ------- <br /> ----- -------------------- --- <br /> l <br /> License Phone <br /> Installation will serve: � � Residence ❑ Y Apartment House Commercial ❑ Trailer Court ❑ F ' <br /> M _ �� otel ❑ . Other ' <br /> .•.. ._ . ----------r---- --- --- ---..:-- --'---- -Nui <br /> ------- <br /> Water <br /> of living units:_._ <br /> -._:-----_Number of bedrooms_-- --._Garbage Grinder"--.".____--Lot:Size------------- ------- <br /> l <br /> ter Supply: Public System and name_,___ -- ''_ <br /> ---=------------------..:----------------------------- ----------- --------- --- --_ e <br /> � - .- - ------- -------- -- -- -Private '� <br /> Character of soil to a depth of 3 feet: ; Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ S; <br /> [ Hardpan'❑ Adobe ❑ Fill Material__ .... ---If Yes, type------------------- -- <br /> ------ - i <br /> (Plot plan, showing size of lot, location of system in relation to wells, bi+ildings, etc, must be placed an reverse side.) \I <br /> NEW INSTALLATION:. [No septic tank­:'or `seepage pit permitted if.public sewer is available within 200 feet,) t i <br /> PACKAGE TREATMENT [ ] ,r SEPTIC TANK A .I ' <br /> [_] Size - -----------------: : -- <br /> --------- ---- ---- ------- - ----Liquid Depth.-------_------'--- <br /> _ --- -- <br /> Capacity,-----" �:____ _.Type.---=I--= <br /> ' -----Material--------------------------No. Compartments---------- <br /> ------------------ <br /> Distance to nearest: Well.: ----------Foundation-------- Prop. Line--------- <br /> LEACHING L <br /> - ' <br /> - , <br /> I .INE ; <br /> [.1 No. Lines ----- ------ ------------ Length of each lin&.-------- ---- ------.Total Length.-----.----------- - <br /> ------------------ <br /> 'D' 'Box--s_---.'_-Type Filter Material"-----------------Depth Filter Material--- <br /> ----------- - <br /> .Distance to nearest: Well Fo t - ---- <br /> undo ion_________________ <br /> r. Pro perty Line--- --------------- <br /> ,._, - _ <br /> SEEPAGE PIT [ l Depth----= -----= ---biometer------- �------=--- Number � �.. � ,_.. , .- ----- ----- <br /> Ye <br /> ;. .. i . .. Rock S z <br /> __. __ <br /> Rock Filled No <br /> Water Table Depth_- <br /> . , <br /> Yes <br /> ' = : e' = ---'- <br /> Distance.to nearest: Well--------------------- ------.Foundation--_--------------- -- -- . <br /> EPAIR DDITION [Prev. Sanitation Permit#_..___-."-_."--___" .__ Pr 1ne___._._.___" <br /> Prop. L' ---- <br /> - --------- - ==-----Date-�---: � ----=-=_-._-_.---- - ._.. ;, <br /> Sep is .ank {Specify Requirements)----- -_-. _ <br /> _-----} <br /> ------ <br /> Disposal field [S ecjfy.Requ' ements)-_ = <br /> Q ------- - -- --- r <br /> U <br /> - <br /> -- - <br /> �72 ------------------ <br /> ---------------.- - --f:-. ---- _ -.- .------ -- ---------- -. -- ----------- -_ ---------- --------- <br /> ---- --- -- ---- <br /> _ = <br /> t. = - -------- -----=------------------------- -row <br /> 3. [Draw'existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that thework 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'perforriiarice'of'the work for-which this per is issued I shall not employ an ' <br /> to beco L ubjeat to Worm n•s Compensation laws of California." P y Y person in such manner qs <br /> Signed .. <br /> -{--- ------ -- --- ---- -- ---=-- -------- ----' 'Oven&r <br /> By ------------------------------ <br /> -t <br /> ---- w-------- <br /> ` ite - <br /> -""{!f other ner) <br /> FOR DEPARTMENT'USE ONLY E <br /> APPLICATION ACCEPTED BY__- w <br /> . ------ ---- -- DATE. z_7 . _ <br /> DIVISION OF LAND NUMBER.------:------- -" " = --- <br /> ----- ---- --------------------- -.------------------------------- ------DATE-------- <br /> ADDITIONAL COMMENTS--------------- -------- - <br /> -------------- - - <br /> --------- --------------------------------------- ---------- ------------ -- ---- <br /> Final Inspection b ------ ------�-->--------- <br /> p Y TM ---•.°_ _Date <br /> ----- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 Rev. 7/76 3m <br /> 13 24 <br />