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FOR OFFICE USE: FOR OFFICE USt <br /> �/ APPLICATION FOR SANITATION PERMIT. "I <br /> --------------------------------Z�-7)----------- it- (Complete in Triplicate) Permit NO...114- 71f <br /> --------------------- -- -Z <br /> ............. Date lssued.�� -:""---- <br /> ........................ -----­--­---------­ This Permit Expires I 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 Grid-existing Rules and Regulations: <br /> Z. L._CENSUS TRACT.-_--- <br /> JOB -------- --------------- <br /> ADDRESS/LOCATION ---- ................. -- -- --------------- <br /> Phone5p.�_Jr ......... <br /> Owner's Name...... ......... . ..... ...... _d� ........ ..... <br /> Z i p <br /> City.Address.... <br /> Contractor's Name--- ---- .................. .....License <br /> # d011.... .Phone.j <br /> Installation will serve: Residence E] Apartment House E] Commercial F] Trailer Court E] <br /> Motel ❑ Other- <br /> Number of living units;..... -------Number of bedrooms....c>2- Garbage Grinder---------_Lot Size__4!. --r.-.17 . ..... .. <br /> Water Supply: Public System and name --------------- .............. -------------------- --------------------- ------ -----------Private <br /> Character of soil to a depth of 3 feet: Sand Ej Slit El Clay El Peat E] Sandy Loom El Clay Loom E] <br /> Hardpan E] IAdobe V 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 INSTALI.ATION. (No septic tank or. seepage pit permitted if public sewer is available within 200 feet,) <br /> e - .-Liquid Depth---- ------------ <br /> PACKAGE TREATMENT SEPTIC TANK Siz ----------.--------------- <br /> ------Na. Compartments.-- `--- <br /> -- <br /> Distance <br /> ... M teria ........ <br /> Capacity/R4---0---- .... ... <br /> nclation---- ..Prop. Lin <br /> Distance to nearest: --------- --- - ........ Fou <br /> LEACHING LINE No. of Lines :il..../................Length of each line,'Avlo... ........ ... Total Length ------ <br /> t <br /> al 6,64)�.Depth Filter Material..... A? ........................ ------- <br /> 'D' Box._. ........Type Filter Materi <br /> n__1":t- -.Foundation.-_477_10... ------.Property Line....? 4--------- <br /> Distance to nearest: Well--- - -- ...... <br /> ' e 01 Rock Filled Yes g?" No <br /> SEEPAGE PIT [4K Depth ------ ----Number- ..--------_------------------ <br /> Water Table Depth--------- ----------------------Rack Size...- -- ---------:_­'�----------- <br /> Distance to nearest: Well---- . ......... .... .4_t_..- Pro ------ --­ <br /> REPAIR/ADDITION (Prev. Sanitation Pe'rmit ............... ---------­ _....-..-------Date.-----:----..--------.......------- -----------) <br /> Septic Tank (Specify Requirements)__ !.................................... .............. --------------------------------------­ --------------­­_­.. .......... <br /> Disposal Field (Specify Requirements):.... -"- .............. . ............. . ...L--------------------- <br /> ------------ ------------- _....................... ------------ <br /> ----------------:...... ------------ ------------ ------------------------- <br /> ...........I---------------------------- ------------ ----------- ­.1___­­.......... <br /> --------------­_­­....... ........................ ... ---- ---------------------­ --------------­ ------------------------ ...... <br /> / I (Draw existing and required addition on reverse side) <br /> I hereby certifythZ_�Ih,v'e .prepared this application and that the work will be done in accorclanke with San Joaquin County <br /> Ordinances; State Laws,' an-d .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 become unb* t t f California." <br /> . <br /> . j c a ]Wor,,,man s ompensation laws a <br /> --------- <br /> Signed-. ----- Owner <br /> -- <br /> By------------------------ .......1­ . . .- .......Title.---------­-----------�_ - --- ---------------------- <br /> (if other than owner) <br /> FOR PIEPARThft"SE ONLY <br /> APPLICATION ACCEPTED BY...---....-- ...... ... E ..... . .. ... <br /> DIVISION bF LAND NUMBER. . ....... ------ --- DATE--------- ........... ... .... ........... <br /> ------------------- ......... ....... <br /> ADDITIONAL.COMMENTS- .... .. <br /> ........... ------ -------- ---------------- ------ <br /> ------------- -------------- ------ ------------- ---------- ...................... <br /> ---------------------------------- --- <br /> Final Inspection by: ...... ... --------------------------------------------------- ............Date. �;....... <br /> EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />