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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No-------------- - , <br /> --------------------------------------------------------- <br /> ----------------------- (Complete in Triplicate) ' <br /> _.-�ra1 � <br /> Date Issued_ ." J'7 <br /> --------------------------------------------------------- <br /> ----_----.--,-_ This Permit Expires 1 Year From Date Issued <br /> --------- --------------- --------------- J <br /> uct and install the <br /> Application is hereby made to the San .Joaquin Local Health <br /> District <br /> No. for and existing Rulconst <br /> .r and Regulations: work herein described. <br /> This application is made in compliance with County _ } <br /> CEN . <br /> SUS 71jAC <br /> IOB ADDRESS/LOC TION. ,��? Q <br /> --- - ----------------- <br /> ----- o.e <br /> Owner's Name_ ---- - --- I? Ph� -----"- �. <br /> (/�� / 3 <br /> ' � /� 9y/r --�'-�` ------ -- City � - ,----- �?-- ----- <br /> Address_. <br /> '�--_� -- ----- _ License #-303.7 --•- -Phos ���--_ � <br /> Contractor's Name -- +-. <br /> Installation will serve: ResidenceApartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_- ' \ -------------- ----- <br /> t --.-_.Garba a Grindex_------- ---Lot Size___._,._���"------ ------------------ <br /> 0 ---- ' <br /> Number of living units:__[_.--- "-"--Number of bedroms.__ Privateel <br /> Garbage � � <br />[ Water Supply. Public System and name------,-------------1 Sandy Loam ElClay Loam 1FE� <br /> Character of soil to a depth of 3 feet: : Sand ❑ `Silt❑ Clay El Peat❑. ' <br /> Hardpan F-1 . Adobe ❑ <br /> Fill Material-- --------If yes,'-type-------------- -=---------- -- <br /> - s� 1 <br /> k (Plot plan, showing size of lot, location of;system in relation to wells, buildings: be placed on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer s`'available within 200 feet,) <br /> SEPTIC TANK [AYE <br /> Size_6_X5 e E Liquid Depth._ !Z <br /> PACKAGE TREATMENT (-] �. € Z <br /> �+�- - V--'No. Compartments <br /> �__�� -"_Matexial____4--_>� <br /> Capacity-Az*0---- ---Type �"t�` � / , <br /> .. ---------- <br /> { Distance:to nearest:'Vllell.__. -- <br /> -- ------------------Foundation'---1-�-r-----:------ -Prop. Line-_�1 ------- <br /> g_ -- .. f .-O ----- <br /> LEACHING LINE [�' No. of Lines "',- ----- Len <br /> Length of _--�` 'd �"y Total L�rgth.__ _"_--- ------------------ <br /> , / "Depth l�7laterial',_ _- ----�------------------------------ . <br /> 'D' Box._/_---...Type Filter Materlalr/: / <br /> 11 <br /> ` k !� F.ounItv �dation- ��Q�------------Property Line.-- --- ----- ---- -. <br /> E Distance to arest: Well_ _ - --_- [ <br /> De th ��------Diameter. {a�-------.Number------------------------ ---- { Rock Filled Yes No <br /> SEEPAGE PIT [� p y� <br /> ------- -- Rock Size,-, < L'. <br /> ------------------- <br /> Water Table Depth._ -��f�-----------------------� � „. r_--.. t � <br /> Distance to nearest- Well`-,.#. --- - Foundation_-5a---- --------Prop, Line- -- ----------- <br /> ` Date_ -------- = --------1 <br /> REPAIR/ADDITION (Prev..Sanitation Permit# .' <br /> ;> t <br /> + 1. ` ------------------------------------------------------ --- s r <br /> r <br /> Septic Tank (Specify Requirements}.____--------------- -- l - ”, ! -(syy <br /> +��.-6------------------------------------------------ <br /> Disposal Field (Specify Requir ents)-------- .- ----- ------------------------------------------------ ---------- ; _ Fj <br /> � ., <br /> [ ---- ;.--------------- , 11 <br /> _ <br /> ------------- <br /> ---------------- ------------ -- <br /> t <br /> g <br /> ' [Draw existin and required addition on reverse side) <br /> ► l hereby certify that 1 have prepared this application and that the work w ill'be done in+accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of thep.San Joaquin Local_Healt". i3trict. Home owner or licensed agents <br /> signature certifies the following: ! � <br /> s <br /> I "I certify that in'the performance of the work for which this permit is.issued, 1 shall note ploy any}person in such manner as <br /> to becoWsubjo Workman's Compensationjlaws of California.tS+gned - ------ -------- ___If other than"owner) , <br /> FOR DEPARTMENT USE ONLY. <br /> DATE. <br /> APPLICATION ACCEPTED E --- -- ------------ ----------------- --- ------------------ ---`-- DATE--------1--------------------=_- -------- ..` <br /> DIVISION OF LAND NUMBER._---------- -- -------..k___ti---------------------------- --. <br /> ADDITIONAL COMMENTS_..-- -------------------------- - ------------------: _ <br /> - '------------- <br /> -------- --------------------------------------------- <br /> ► : -� <br /> ---- ------' -- <br /> ------------------------------------ <br /> -=-------- <br /> ----------- / �J" <br /> ' + Date ��! ( = <br /> -Ins Inspection b - - - - - -- -- - ---- ------ -------- -------- - - � - r <br /> -- <br /> Finalp Y' � FM 21677 REV.7/76 3M <br /> ( SAN Y�AQUIN LOCAL HEALTH DISTRICT <br /> EN 13 24 <br /> t 0 a <br />