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fi FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------- Permit No.---77. 1�1�3 <br /> {Complete in Triplicate] - <br /> ----------------------------------------------------4---- rJ 77 <br /> Date Issued.-/-_y_.__._'_--. <br /> -------------------- --- --------------.--------------.._ This Permit Expires 1 Year From Date Issued <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 /> . �i <br /> JOB ADDRESS/LOC TION"___It7c/ ,yG�---U _ y✓,'Jr ---- Q_ .L.li ',�4�..-_-------.CENSUS TRA ------------ <br /> - <br /> Name.----- ---- -- - - --------- ° _ <br /> _ Ph ne , N <br /> � J <br /> Address ----- CItY r -- --Z1P <br /> � ------- --- ----- - �1 <br /> Contractor's Name-. - -- -- --- ----------------------------------License #-_ O '7 /---=--Phone---- _3 ----- <br /> Installation will serve: Residence_ ❑ ' Apartment Hou,yse� Commercial ❑ Trailer Court ❑/ <br /> Motel EJ i Other---/�-/- 3 <br /> ; a <br /> Number of living units:--- _-:------Number of. bedrooms-_21- ---Garbage Grinder:.-:--------Lot Size--------J __`�- -- ------------------------- <br /> Water Supply: Public System-and'name- ------------------------------------------------------ ------- ------- --------- --Private <br /> Character of soil to a-de th of 3 feet: Sand Silt Clay Peat Sand Loam Cla Loam �/ <br /> p ❑ ❑ Y ❑ : ❑ Y ❑ Y _ <br /> p ❑ ❑ ; Fill Material__.__p_ . - If es, type Hardpan Adobe ,- - - Y e --------------- -------- -- - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverseside.) <br /> NEW INSTALLATION: (No septic tank"or seepage .pit permitted if public sewer is available within 200 feet,] <br /> _ � <br /> PACKAGE TREATMENT SEPTIC TANK Size_ Liquid Depth---- ------- <br /> --- - Ma , mpartments ---------/-- <br /> ---------Capacit �, ��c.Type- _ <br /> Distance o-neare.t:-Well......14'V---i---------------------Found ton:..f6--:------ Prop. Line - <br /> ,4 i 1 <br /> `° ', th of each line.-_- -.----- _.-.-":=--,.Total Length--------------------------------- <br /> LEACHING LINE (� No. of Lines------.-- _-.___ --_-;Len <br /> 'D' Box_A5 _- _Type Filter Materiol= __ -��-D pth Fil er Material - - -------_ <br /> g <br /> Distance to nearest: Well--/h�-�___________--Foupndation--a_�---------- -----Pro ert Line-------------_---..---- <br /> SEEPAGE PIT {yam Depth_ ....Diameter--_-3 ----------Number'---- ------------------ Rock Rock Filled Yes EJ.- No 1%L <br /> 4 ` • <br /> f - - <br /> ? <br /> / ----------------------- -Rock,SSize---�Water Table Depth.-- 7Distance to nearest. Well---�61 -- ------- .---- Fo --- ----------.Prop. Line------711 <br /> 5 -i- <br /> ------�--- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------"-------Date'`.-------------------------------------------1 <br /> Septic Tank (specify Requiremen#s)-- ' -------------------- ---------- <br /> -. <br />¢ Disposal Field (Specify Requirements)____----------------------- <br /> f, ' r "------------ -T ---------- ------- ------------------- <br /> ---- ---------= ------------- - ----- ----------------- ------- -- <br /> ----- <br /> ------------------------------ <br /> i (Draw existing and required-addition on reverse side) <br /> hereby certify that I have prepared this application and tFat the work will be done in accordance with San Joaquin Cour <br /> Ordinances, State Laws, and Rules and Regulatio of=?he' San Joaquin Local Health District, Home owner or licensed agen <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 manne <br /> to become.subject to Workman's Compensation laws of California." <br /> Signed------- --- ---- -------- --------=•--------�----------------:--------.---- --C►wner� <br /> By- ----Title- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-- = :.- __ -----------------------------------------_----------DATE --- �Z' = Y <br /> DIVISION OF LAND NUMBER.-:-------- -------- --------------------- <br /> -------- - --------------•-•------- --- ------DATE--------- -------------------------------- <br /> r <br /> ADDITIONAL <br /> --- •--------------------- <br /> ADDITIONALCOMMENTS------------------ ----= ----------- -----------------------------:­------------------------------------- ------------------------------- ------ -------- <br /> --------------------- ----------------------.------------- <br /> - ----- --- <br /> - ----- ---- - ---- ------------- <br /> Final Inspection bY-----__-- - = Date. ia7� REV. 7/76 <br /> EH ra 24 SAN JrAQUINLOCAL_HEALTH DISTRICT s z3>u <br />