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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ' <br /> ......................................... <br /> ....-•............. � Permit Ido. .76 <br /> {Complete In Triplicate) ..". ..... <br /> This Permit Expires I Year From Date Issued Date lasued _...' ? . <br /> - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application Is made in compliance with County Ordinance No. 549 and existing Rules and Regulations <br /> I JOB ADDRESS/LOC A71 N ..... _ � ........ <br /> A <br /> ......................CENSUS TRACT <br /> 4 <br /> Owner's Name � .......................... <br /> Address <br /> �t-... -------------- •---_ . C�t;,� Phone ... ------ <br /> Contractor's Name -_-- -`- - -=, =, ut,License # - <br /> Installation wi l serve: Residence;Apartment House❑ Commercial(]Trailer Court 0 <br /> f <br /> Water Supply: Public system [sem Community system ❑ Private ❑ Depth to Water Table _ ft. <br /> rac er of soi f ,a pn+h n 3 e�• 5� J,D C' M c-..a.. i __ r__1 <br /> der upply: i�u�ilic ystem anWname -r-{T�'���----- — <br /> ••• ..-_--. ----• ------ ....Private <br /> Character of�-soilyyto�a depth of 3 feet: Sand 0 Silt❑ Clay .0 Peat❑ Sandy Loam 0 Clay Loam <br /> Hardpan Adobe Fill Mtericrl <br /> ` ............ if yes,type ............... ............ <br /> y <br /> {Plot plan, showing size of lot, location of <tem in relation towells, buildings, etc. must, be placed on reverse side.) <br /> F <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted'if public sewer is available within 200 feefl <br /> PACKAGE TREATMENT { ] SEPTIC TANK <br /> ► Size r <br /> . �1' - ... •-•-• ... :liquid Depth ..:_ ......_.. <br /> i <br /> Capacity�(T.�'-�•�i�, Type wL '�---- aterlal--- .- _ - _ No! 'Compartm nts '3- -- ----•--. <br /> Distance to nearest: Well - <br /> t• :. ��......Foundation -- ---�_ '..---.'_.__ Pro Line <br /> / l p -----=-•-. <br /> LEACHING UNE" ` <br /> Nd—of Lim 1 '-� f' <br /> ...._ length o each li e.-`, , __..._-.-•-._- Total Length �� <br /> - g -•.............. <br /> r Sox -S1 . T ... . 4 1-' <br /> 4 ype Filter Material - - _ - ----Depth filter Materioll --- ... .:................ ........... <br /> Distance to nearest: Well foundation ....- Property Line ............ <br /> SEEPAGE PIT"V'"""""Depth `f"4`""Diame er ...........1:....._....i' Rock Filled 'Yes No <br /> Rock Size-.:. cy� . . <br /> Water Table Depth ......... �_.. ................. .::....._.... - ; <br /> Distance to nearestWell _._ -- _-:Foundation _.. �i�_. Prop. Line A .......... <br /> REPAIR/ADDITION,(Pr'ev. Sanitation Permit -. .._ .• ._... Date t <br /> Septic Tank (Specify Requirements) .............. I <br /> Disposal Field (Specify Requirements) _ - i <br /> -----------•.....--•------------•.... ...... <br /> ----------- ------------- <br /> y 3 ...............................................•-- ••-- -- _ _............-......... <br /> _ ... Draw existing------•- --------------•--- -------------------------------------- g I.f. <br /> ------ <br /> and required addition on reverse side) <br /> I hereby certify that I have_prepared titia cep pticg1ion_and.Jk9t_the work will be done In. accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home 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, 1 shall.not employ any person in such manner . <br /> as to become subject to Workman's Compensation laws of California." y <br /> { . <br /> Signed .. ------ r....-- ----- Owner', <br /> 1,4 <br /> y -----... title '...: <br /> ......... <br /> (I�ot ,,than`�ownex3 , ' f <br /> i + FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ <br /> ---.-.` - ..- -- ---------­------- ------- DATE j3�._. .._ <br /> �_- !-- <br /> BUIL-6NG:PERMIT-ISWED 'DATE.. <br /> ADDITIONAL COMMENTS <br /> 3 <br /> ----------- •-------. ----•---------... <br /> :... ... ....... ..-..-----------------.--------------- <br /> •-- <br /> ina Inspection by: ..- 74 ---- ..........................' ....................................Date _,.-.�... _� <br /> Eli 13 2!1 1-dFi lay. 5 SAN J AQUIN LOCAL HEALTH DISTRICT <br /> 8/7$ 314 i <br />