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tFOR OFFICE USE: FOR OFFICE USE: <br /> Mp APPLICATION FOR SANITATION PERMIT <br /> 77- <br /> --------------------- -- --- <br /> - {Complete in Triplicate) Permit o_______________________ <br /> Date Issue d__.__ <br /> This Permit Expires",t Year-From Date Issued v <br /> Application is hereby made to the San Joaquin Local Health Distrrct for,a permit`to: on <br /> cstruct.and install the work herein described. <br /> "' <br /> This application ism de in c iance with County Ordinance No. 549 and existing Rul4es and�Regulations: <br /> JOB ADDRESS/LOCATIONf. __,_ �f.#�i__�� _�_._.� ±'���.��"°.".�!�� �_. ' u� -.CENSUS TRAC®T_ <br /> !rC ._ � � il7�yr. ' Phone__? /'' f---- <br /> Owner's Name.:- - --. -�; y E <br /> - <br /> Address �. ���_ tX' �— ; -Zi '' ------. -- <br /> .__K-..t...._. <br /> Contractor's Name- - # � <br /> _ _ c� --- ----_ _._License Phone_ _. <br /> Installation will serve: _ Residence ❑ Apartment House.E Commercial ❑ Trailer Court <br /> Number of -- - Motel Other <br /> t <br /> i <br /> living units: -__'._-__ _Number:of bedrooms1__'�/ Garbage Grinder --- -- Lot Size_._-© _: 4 # _ <br /> € r Silt - ----------------- = F Private <br /> Water Supply: Public System and iname________._ <br /> !� ❑ ! <br /> Character of soil to a depth of feet :.Sand �❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> : t •Adobe Fill Material-------------If yes, type------------------------ ------- 17- <br /> 'Hardpan <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 /> [ )a a ,]—.�..... . ., Size-------------------------------------------------------�----Liquid Depth-'`-\- ------- --- <br /> PACKAGE TREATMENT SEPTIC TANK <br /> -Ca aat --= --- YP. - --rial--------------------------No. Compartments <br /> a <br /> E <br /> Distance to.nearest: Well.-�---------------------- ate- -'Foundation-_____!`"'___ __.___p_rop._Line. ------ ---- - <br /> LEACHING LINE . ( _]. pa.8 XLines...--T-r e Filter 1Nateeagth of each line <br /> De Depth Filter Material_Total Length. :__._.__--------------------------------- <br /> D', <br /> �___l______ __ <br /> t � 6 � YP <br /> .e! ----`� --------- -------�`---------- <br /> Pro <br /> Distant&'to nearest: Well--------`----- Foundation-------------- --- -- � <br /> rty'Line---------------------- ------ <br /> De <br /> SEEPAGE PIT t ---. <br /> th-. -----------Diameter------- Number-------------------------------- RocE]-k Filled Yes No � <br /> [ ] p <br /> Water Table Depth-Well ---.Foundation-----Rock Size :�------=------i----- <br /> ------------ --- I <br /> Distance to nearest: a ---- ----- Prop. Line_.4________.__r________._. <br /> REPAIR/ADDITION (Prev. SanitationPermit#-------------••---------------3-------------------------­------ --------- -_---- - -- - -----------} ' t <br /> Septic Tank (Specify Requirements)-------i---- --- --------- i ------------------=--=---------- ------------- -----.----- <br /> - <br /> Jf ---------------/--- �Ee <br /> =y; <br /> Disposal Field (Specify Requirements) ,� -. __ <br /> ---- -. <br /> ------°_. <br /> ____________________ J� "' <br /> ________'_____ -.______ _____..___-_______-_ .________ _ ___________ ---- '" ------------ <br /> -------- <br /> _ <br /> --------- ------i ------- -------------'- - <br /> �}. <br /> ---------- <br /> ' ' {Draw existing and require- addition on reverseside) � <br /> I hereby certify that I haveprepared -this-application and that the work will -be done- in accordance with San Joaquin County <br /> Ordinances, -State Laws; and Rules and Regulations of the San Joaquin Local'Health District, Home owner or licensed agents <br /> signature certifies the foil'-owing: <br /> "I certify that in-the pei'for"marice of'the'work for which this permit Wissued, I shall not employ any person in such manner as <br /> to become subject to kman's ompensation laws of California." J <br /> Signed-- - ---- ---'- :: --.-.---Owne' �' <br /> ,r <br /> B �.,� `w C1i Vic. JJ [l/. ' <br /> By- Lll�_ - <br /> If other than owner <br /> '-FOR DEPARTMENT USE PNLY _ <br /> r <br /> APPLICATION ACCEPTED BY - = <br /> ---------------------------------DATE �. .T <br /> DIVISION OF LAND NUMBER__- -------------- <br /> UMBER.. _-;--------#---- - -------------- .----'-------------------------- ---- - ------DATE------ --- -------------- -.----------- <br /> . <br /> ADDITIONALCOMMENTS------------- ---- --------- ----------- ------------=--- -- -------------------------- -------------------------- -------------=--------- ----------------- <br /> -------------------- <br /> ---------------- ' <br /> --- <br /> ------- -------- ------ <br /> ----------------------------- <br /> --------------------------=-------- ---- - ------------------------•----- -- --=------- -- --- = =--------- --------- - - - - <br /> - } <br /> --- - -- <br /> Inspection by - - Date.._-_-_Final - - --- <br /> SAN JOAQUIN LOCA HEALTH DISTRICT <br />