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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------- <br /> Permit No.-_.7f-y��-l-1 <br /> - --------- <br /> ------------------------- --- (Complete in Triplicate) <br /> ------------------------- <br /> ----------------- <br /> Date Issued.- �° 7 <br /> This Permit Expires 1 Year From Date Issued <br /> ---•----- --- ------------------------ <br /> I k S�✓� lam✓, c'VT <br /> Application is hereby made to the San Joaquin Local Health :District for a permit to construct and instal the work er �n escribed. <br /> This application is made in compliance with County Ordinance No. 549 and exiting Rules and Regulat�4 o g7. 41 <br /> JOB ADDRESS/LOCATION.=..: -Z.7-- �:�-- `---�'�=-�----s-.�`=1�.'�_T/Z�- --------------- ----------- CENSUS TRACT6� ------r�--�?------- <br /> JOB <br /> ----$ -- one_- -77-7,-.-- <br /> ------------------------- - <br /> Owner's Name--------- - <br /> ----- -------- ------ - ------.-. <br /> 4N -- -------- ------------------------ -- - <br /> s: "., CityZi>' <br /> j i -- <br /> Address------ ------------ ---- --- --------- ------ . .. . <br /> aI ---------------- <br /> Contractor�Name1r- --- - .-------- : -------- <br /> License #.-------- - ------------------Phone_ <br /> Installation will-serve: Residence k,.Apar`ment`House.❑ Commercial ❑ Trailer Court ❑ 1 <br /> Motel- Ofhef-------------------- ' <br /> s ! �/ -- - -------- ---- <br /> Numberof living units:-- ____Number.,of.,-beerrooms=_-`T-"'Garbage.Grinder---,-..=_.Lot Size.--.-- _-.-_. .__ _ a <br /> I <br /> -------------- - <br /> -_, --- - - Private <br /> Water Supply; Public System and name--.- ---------- --------------- -a----- _---_--- . <br /> Character of soil.to a depth o 3 feet: Sond j] Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam [:1 <br /> Hardpan ❑ ' Aclobe❑ Fill Material------------If yes, type--------------------- --- <br /> (Plot plan, showing size of lot, locati li of system in relation to wells, buildings„etc. must be placed on reverse side..I <br /> NEW INSTALLATION: ,(No septic td k .or seepage pit permitted if pIf ublic sewer is available within 200 feet,) <br /> Size---'.l J `-r �g---- -------------liquid Depth..&-`�. <br /> �-' <br /> PACKAGE TREATMENT [ ) : SEPTICTANK M)C1 f <br /> Capacity-//,471 --.Type-.0-00-t �.--Material----------------'--------No.�Compartment ------ <br /> 1 , <br /> A Foundation..-- -=--- == P_rap. Line-._}✓�d ; C4 <br /> Distance to nearest: ------ --- <br /> = r <br /> # t <br /> LEACHING LINE _ I 1 No. of Lines-----:� - _------------ ength-of_each,lina.---- --------=---------__-.Total `erigth._.----- -Q----------.----- <br /> r <br /> j D' $fix---`--.Type Filter Materi --/ r! ------Depth Filter Material-- -- -------------------------------- <br /> D' <br /> ----- ------ ; <br /> -- - <br /> o <br /> Foundation__." U --- ;V:Property Line-Il Ye (�' N ❑ <br /> .,,.,..Distance to nearest: Well i - <br /> Rock ed <br /> - �, F, I s o. <br /> De th.w -- -----Diameter-/✓P-------=----Number------ s <br /> SEEPAGE PIT :I ] p -7 <br /> ------------------- <br /> I Water Table'Depth------------- - �--------------------- Rock ize -- <br /> ---- R k .S �-�- � <br /> I - ' � <br /> ' Distdnce.to nearest: Vllell_ - UD_------- ---------------Foundation---.- 0 --- '-.Prop, Line.----/ v---------- <br /> ---- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-_--_---`--=---=-- <br /> --=----- ---- --- ----------Date--- --------- ---------- -- ----} <br /> ------------------------------------- <br /> 1 Septic Tank (Specify Requirements)--- =--- -- -- = -_ -------------=------------------------ <br /> Disposal Field (Specify Requirements) - ---- <br /> ---------------------------------- <br /> ---------- -: , <br /> ( _ <br /> ---- -- ---- -- <br /> __ __ _ - ----------------- --------------------- -- -'---- -----r <br /> -------- <br /> 0 <br /> u <br /> (Draw existing and required addition on reverse side) ' <br /> application q <br /> ation and that the work will be done in accordance with San Joau'sn County <br /> I hereby certify that.) have pT repared this app ' <br /> San Joaquin Local Health District. Home owner or. license <br /> Ordinances, State Laws; and Rules and Regulations of the_ d agents <br /> signature certifies the following: - i <br /> person in such manner <br /> "I certify that in -the performance of the work for which this permit is issued, I shall not employ any p as <br /> l <br /> f to become subject to. Workman's ,Compensation laws of California." <br /> Signed--------_----- --------- 7 = = _ --- --- . -- . <br /> ----- Owner <br /> --------'- Title <br /> ---------- - <br /> (If other than .owner) <br /> I <br /> i­a­.- 01111 FOR-DEPARTMENT USE ONLY, A <br /> ------ --------- =------ --===--' =-`-=---- --.DA -- -- - ---- ----/dam:��� -- <br /> '- <br /> APPLICATION ACCEPTED. BY-__.�� :--- . <br /> ATE <br /> :. <br /> DIVISION OF LAND NUMBER --- --''-- --- ----= = <br /> f ADDITIONAL COMMENTS---------- -----4 ----=- - --------------------- -- --------- ------------------------ <br /> -----------------1 ------------ =---------- --------- <br /> ---------------------- ----- <br /> - --------- ------------------------ Date —�— ------- <br /> Final Inspection b ---- ------------------------ <br /> - --- --- � F 21 REV. 7/76 3M <br /> ► EH 13 24 SAN JOAQ LOCAL HEALTH DISTRICT <br />