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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - <br /> .._.,_ .s .- .� _- a. Permit No. 77r <br /> IContplete in Tripltcatel ---- <br /> �..�. .. <br /> issu3# <br /> Date ed .2- 7 7 <br /> This Permit Ex ires ? Year1rom Date Issued """" """"" <br /> t <br /> Applicibation is hereby made to the Son Joaquin Local Health District: for a permit to construct and install the work herein <br /> descred. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ,I <br /> JOB ADDRESS/LOCAT ON ....�......o /i ......................... ......................CENSl15 TRACT :..,...................... <br /> Owner's Name ....Phone ......... <br /> Address yp .... . ..... .......... <br /> 4�.......`. ..---�-C..�..--a*-y,.� ................... �.......city � .-., � <br /> Contractor's Name �J.�nc<aair.. CA.�......:. ..... ........'........License G� '........ Phone .............................. <br /> Installation will serve. Residence E!�Apartment House Commercial 0 Court <br /> Motel []'Other ................:......:r..... <br /> Number of living units:....... Number of bedrooms �....Garbdge_Grinder R Lot Size .....1....................... <br /> Water Supply: Public System and name ....:..................................------::....---................F ......:...:...:..................,...Private ®� i <br /> Character of soil to a depth of 3 feet:, Sand❑ Silt❑ Clay ❑i. Peat❑ Sandy Loom 0 Clay Loam ❑ <br /> Hardpon o Adobe;m--,l'III A+laterial ............If yes,type............... ....... } <br /> (Plot plan, showing size of lot, location of system ki 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 [ ] SEPTIC TANK . Sixes /.d.�.t'. .............. <br /> ....-. Liquid Depth ..�/.................. 3 <br /> Capacity lire- . Type/ Materiai... .:... No. Compartments ..: .,............ <br /> a .Foundation f ate.__ Prop. Line ...' `r 1 <br /> Distance.to nearest: Well .---..-.... --••..•--....-.. ........ <br /> LEACHING LINE it,/ No. of Lines ...... .......... Length of each line.---17iV_�'--.------ Total Length ...r✓ �, ...... o <br /> D Box ..--.1..... Type Filter Material' ....._�I?IL .Depth Filter Material .....1.�f.-............................... �o <br /> A �� J . <br /> Distance to nearest: Well �Q .: Foundation ...... !� .. Property Line ....'�`�/"'...:: . tt <br /> SEEPAGE PIT { Dep}h ...... Diameter Number ..........3`... ............. Rock Filled Yes 0' No C3 <br /> ...�. Water Table Depth -•---_--- .-......:....:..........Rock Size ..... �o <br /> Distance to nearest: Well ----- �� ;-:-•- :__Foundation` ___«' r.. Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _.........-..........................:...... Date ........... <br /> Septic Tank (Specify Requirements).................:. .............................................. .........._......_.................. <br /> Disposal Field (Specify Requirements) ..................................... ..- .:-.....--........_.............-----.....------•--•-...........:I......--... _ <br /> •----------------------------------- ---------- --------------------------------------------- --.....------.........-----------------------....---•------------------------------------- <br /> ,j -- - ------ ------------ ..................................... <br /> Draw existing and required addition on reverse side) <br /> I :hereby certify that I have prepared this application and that the work will .be done In accordance' wills San Joaquin <br /> County Ordinances, State laws, anis Rules and Regulations of the 'San Joaquin Local Health.blstrict. Horn* owner or licen- <br /> sed agents 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 a <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------------------i............... ........._ Owner <br /> Y ------- ----- ----- C - <br /> B :........ 7.itle - . <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----.. - - <br /> � ] <br /> -"�•-- - .. - --•-------•-- -- -------------- ----­------- <br /> BUILDING PERMIT ISSUED .-- ................. DATE :. <br /> ADDITIONALCOMMENTS -•-----•-"---- '.....................- ............................ ....................-................................................ ................. <br /> .............................--------------------------------_---------.---..-........_»-.-------------------------------.-------------------------.---------------------._••--.•--------------------.......- <br /> - -- --- -------------- -----------------.-... ----------------- .. ...... .........-...__•........ ... .. <br /> - <br /> -------------------------------------------' <br /> 2 <br /> Final Inspection by- --- -------- - =--��---------=------------------.....-.............--------------------------.-......_-.-bate -•.--- ..-- - �!'-'",�7- -- •------ <br /> EH 13 2L 1-613 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7$ 3M <br /> ' i <br />