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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete inJripIicate) Permit No-7Z-7- <br /> .(�� <br /> f <br /> --- -------- ----- This Permit Expires ] Year From Date Issued Date lssued_.1��-- ~7� <br /> Application is hereby made to.the Son 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 /> JOB ADDRESS/LOCAT10M� / __. 5 ._�'...f .��"�..CENSUS TRACT-_....... <br /> � <br /> Owner's Name 1r.----- e.p] ...--- Phone.. l <br /> Address �� `-1 ---..` YL ----------------------- --- Cit ��--. - q 5& ...... <br /> Contractor's Name---.--. {� 7R >� ' Q .1 -.................. ......License #.. �'' ..Phone---�� _.... ._t.'��... <br /> Installation will serve: Residence %. Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------------------------------- <br /> Number of living units:------ _......Number of bedrooms-_. -.Garbage Grinder.....1-----Lot Size......... . ...4'.e----------------- ............. <br /> Water Supply. Public System and name...... - .. ..._.............................................................Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt[❑ Clay ❑ Peat ❑ Sandy Loam K Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material.. ---- _._If yes, type---•---------------------------- <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 /> PACKAGE TREATMENT [ j SEPTIC TANK D6 Size . ---. --- --- -U " ------Liquid Depth---:•-------------------- <br /> Capacity_UtO T Type CeJA Material-------------------------No. Compartments..---- A�.--------.._--------X <br /> Distance to nearest: Well........ Q�... .....................Foundation....LC). . ...... Prop. Line.---IL5_P........-- O <br /> LEACHING LINE [ ] No, of Lines _......3................Length of each line..------140------------- g <br /> - ----. Total Length ....... .........•-- <br /> 'D' Box.....(......Type Filter Material.0L ..... .....Depth Filter Material-- ------��--------------------------------------------- - <br /> t t <br /> Distance.to nearest: Well_..._._�QO-Q_... ... ..Foundation._:�'P..'.................Property Line..:.... .---.. <br /> SEEPAGE PIT [ ) Depth. 2_12 _...Diameter...751V---------Number-------------- <br /> 3--------------- Rock Filled Yes J[ No[f,, <br /> Water Table Depth Rack Size. Oh_ ---------- --•-------------- <br /> Distance to nearest: Well-----------...ori.................------Foundation------%-D©...........Prop. Line.......--1�1�. ........ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....__...._..._: -----------Date........:..... ----.....) <br /> Septic Tank (Specify Requirements). ....._ ----- --------------------------------------------------------------------------------------------- ---•--- ......... <br /> Disposal Field (Specify Requirements) ---------------------- ............................... <br /> - <br /> ..............................---------------------------------------------•--------------------------------- -------------------------••--------------------------- ......---••-..-----------.._..------------ <br /> -----•----•--•- ............................... ---- ...----------------------------------....------...-..----------------------------.........--- . ...---.....------------------. ------......._.._. <br /> 1 <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State_ Caws, 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 becomeG ject to W,rkma Compensation Taws of California. <br /> Signed----- Owner <br /> By.................. ------------- - •-•------- -- ........Title.- - _------_--- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> APPLICATION ACCEPTED By � r% ..... ........... d L"................ DATE . . <br /> DIVISION OF LAND NUMBER...--- - -- ------.DATE------------------- --- ----- <br /> ADDITIONAL COMMENTS._... .._.__1-._0 A .... A4G.W" -S-5......----��4.T�.r�-------. ........... ate ...... <br /> W..S.4ec7Z�t..cJ--------- -- - - -_.....-----............ ----...-----......- .- - . .--...... --------- . ------. <br /> •------------- ---------------------------- ----------------------------------.------------------------------------------------ ........ . <br /> .....................•..................- ......-- <br /> -------------------------------------- •------------------------------ <br /> Final Inspection by: G - ----------------•------------------Date........ <br /> iJ d � � ........ <br /> F&5 21677 REV. 7176 3M <br /> SEH 13 24 �AN JOAQUfN LOCAL HEALTH DISTRICT '~"' <br />