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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No..71.-.5 . <br /> .-•----• .. <br /> � (Complete in Triplicate) , <br /> -------------------- ------------------ ---- <br /> -------�- Date Issued.-.�....?.'�a:.---- <br /> This Permit Expires 1 Year From Date Issued <br /> J. <br /> ,, t <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_C?rdinance No. 549 and existing Rules and Regulations.,,_ �. „ <br /> V _ . . , <br /> _ . <br /> -----.CENSUS TRACT--- •---------- ----------- <br /> JOB_ ADDRESS/LOCATION.... �� . .... <br /> Owner's Name...0D� � �....�... <br /> ..... .... Phone <br /> -- :--------------- --- <br /> ........... ..... ...... <br /> Address ----. -LIP:-- ...----- .... citY <br /> -T <br /> Contractor's Name.-..� l� f.---... --- [- - --License #.._------- - ------ -� - <br /> Phone------- -------'t' <br /> --- �--- <br /> ---------- <br /> Installation will serve: Residence ❑ Apartment House-D' Commercial ❑ Trailer Court-[9 <br /> I Motel ❑ Other. ;-.r..:-±.A `- `- ----------------------- <br /> 1 <br /> Number of living units;-----/.---------Number of bedrooms.:.:_:...:Garbage-Grinder------------Lot Size..- ----•----- •--------- <br /> Water Supply: Public System and 'name... '... ..........I._...._ - - ........... <br /> Character <br /> -.Private El <br /> I [ i . <br /> Character of soil to a depth of 3 fbe'_t: and El Silt E) Clay ❑ Peat ❑ Sandy Loam 0 Clay Loam ❑ <br /> _ .„ <br /> Hardpan 'Adobe ❑ 1 Fill Material....... ....if yes, type-- ---- <br /> (Plot plan,-showing size of lot, locationof system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW .INSTALLATION: (No septic tank or seep i ;°pit permitted if public sewer is available within 204 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ to Size-------- ---------- --------- ='- �-- ...... Liquid Depth.- <br /> ' CJ .-..:No Compartments......_x" <br /> Capacity/-ZOO..._.....Ty pe 1'._��..----.------Material.._ - ----- --- e <br /> ...... ---.f=ound ion_.--7 - ....-- ...Prop. Line.../c50-------------- <br /> •. � istance�to nearest: Wel•1'�-/.ply-�-�----��� ---- i <br /> LEACHING LINE [ No. of Lines ...-- --...- ---:•-.-. Length of each line.---- V/ ---------- Total Length ....... ! ....-- ------ <br /> 'D' BoxA. ..'.Type Filter Material:S�'- - --.De Filter Material---------- ------------------ <br /> Distance[to nearest: Well...7U�� ....----- - Foundation.---. .----•------.....Property Line-------------- ----- <br /> No <br /> SEEPAGE PIT Depth---� -- .Diameter.__'1/LU_.+...Number--------.1--------- ------ •- Rock Filled Yes ❑ <br /> I <br /> Water TablerDepth------••--------•-••-Y--.f....- - .- - -- •.............Rock Size......- -.....�- -..........-•----=--------- -- <br /> �= Foundation.......L.(7..�_... _Prop.,Line. <br /> Distance to nearest: Well------ ; <br /> f <br /> ...t = -----} 3 <br /> REPAIR/ADDITION (Prev, Sanitation Permit#....--.:'---- --- Date <br /> i Septic Tank (Specify Requirements).....- --__ Y `� {[ ___.. <br /> N <br /> Disposal Field (Specify Requirements)......---------. : ... " '`""--------- ----- -------------------------------------------------- ------ <br /> I f <br /> :... :... •-•-- ...... -- �. <br /> __-: <br /> -k i , - ---- ------ •------------ F-----------------------•----------��.-----. .......----......------- <br /> --- -------- <br /> ------ ------------ ------- -•---- -- ---. - <br /> } (Draw existing and required addition on reverse side) 4, <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. <br /> or}licensed agents <br /> signature certifies the following: 1 [ _a <br /> 1 "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 /> E to become s ct oto Work n's Compensation laws of California." <br /> f <br /> .......Owner <br /> ---- -- <br /> t., <br /> Signed-- -- <br /> - � ..._..-...Title..... --....�-.. .....- ------- --�............... .... �-- <br /> (1f other than owner) <br /> FOR DEPARTMENT USE'ONLY <br /> APPLICATION ACCEPTED BY .....---- •-•------- ....- ----------------------- <br /> ----.....D'ATE ---6�. '.a." 1�'...... <br /> DIVISION OF LAND NUMBER' >i . . •-------- ------ DATE.... <br /> Ile <br /> ADDITIONj� COMMENTS.._. <br /> (��'' <br /> - --------------------- <br /> o^h•�f/v r.. r I <br /> -- <br /> ­­ <br /> -------------- <br /> ----------- ...... ------------­----------------------- - ------- <br /> .. .-------------------------- <br /> - -- -------------- . ---- ------ <br /> _ .,._... __... -- -Do ---- <br /> Final <br /> --- <br /> Final�'Insp6mon by:----- SAN JOA <br /> F85 21677 REV. 7176 3M <br /> EH QU! LOCAL HEALTH DISTRICT <br />