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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit ----- -------- V, <br /> _71------------------------------------------- -------- No.__ ?7 <br /> Date Issued-/�_ <br /> ---------- - -- ---- --------------------- This Permit Expires I Year Frorii 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 /> ------------------------- ----- - ------- --- - -------------------------- ---- <br /> �N CENSUS TRACT--------------------- <br /> 'JOB ADDRESS/LOCATIC <br /> Ovuner's Name--- :Zq(- -e--Affr------- ---------------Phone----,/4 <br /> Address ------I City-Zd1_a.X ka_C�- --------------Zip---- <br /> Contractor's Name-------__.__------I— ------------------- ---------- ..........-------`r---------------------------;License #----------- --- ----- -----Phone----------------------------- <br /> Insiallation will serve: Residence'- Apartment House.F] Commercial E] Trailer Court' F] <br /> ...... Motel-E) Other--- ...... 4S\ <br /> -------------------- ------- -------- <br /> • <br /> Nu`mber of living units:-_'_-.- -------Klum'berlof.beldrooms.-3 Grinder--_I-------Lot Size._-._-.- <br /> . <br /> ize-------- <br /> ---------------- <br /> _4r ------- <br /> Water <br /> ---Water Supply: Public System and.name---- ---------- - ------------------------------------------------------------- ........................Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt[] Clay ffi Peat Sandy Loam Lj Clay Loam E] <br /> Hardpan Adobe El Fill Mcitericil__:------If-yes, type--------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,':etc. musf-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 TANK7jA Sizei_1___J------ Zcxf)_ —------------Liquid Depth.- <br /> 0 --- -------- --- <br /> -rial Compartments______`?___________---------- <br /> --i Ca pa city-.-12-016_,I­1TypenT1V-C_aV- ­ _Material.C���N!�. C <br /> ..'Distdnce'to nearest: Well-t..—__zon t d -----Prop. Line___6C ---- <br /> XQ ----- <br /> ----- <br /> ------2_____\��__Foun ojqn,;----I --- <br /> --------- <br /> LEACHING LINE. _��------- ------Length of eaCK-lirie,---- Total Length ------ <br /> 'D' Box_'IiL5__ <br /> Type Filter Depth Filter Mbterial-----__._143-1-1-------- --------------------------------------- <br /> Distance to nearest.. Wel!_:--- ----------------------Foundation-------25----- ------�___.Property Line-----------------I- -------- <br /> --- <br /> SEEPAGE PIT I Depth..--2-5-'----Diameter-;- ---Number---------- ------ ----- Rock Filled Yes No <br /> Water Table.De" ----------- --------ftri --------------------Rock Size------------------------------------------------ <br /> ------- F 87Tf i 6 ri---- <br /> Dice to nearest: Well---------_----- - ---------- uMd E -----------Prop. Line---.- ---- <br /> REPAIR/ADDITION (Prev. Sanitation Permit-#----------- .... ........... ....... -------— , -r___--"-----'------ <br /> ------ <br /> - <br /> Septic Tank (Specify Req0irements)_.__J ----------------------------------- ------------- ------------------------------------------------------------ <br /> -- ----------------- ----- <br /> Disposal Field (Specify Requirements)-------------------- - --------------------------------------- -------------�.,; <br /> -------------------------------------------------------------------------- <br /> ---------------------- -------------------------------------------------------- -------------------------------------- ------------------- ------------------------------------------ <br /> ----- --------------------------------- ----------------- -------------------------------------- ----------------- ------ -------------------------------------------------------------------- -------------- --- <br /> (Draw existing and required addition'on reverse side) <br /> I hereby certify that'I have-prep a red this application and that the work will be done in accordance-with Son 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 following: <br /> "I certify that in the performanice'-df Ae work for which this permit is issued, I shell not employ any person in such manner as <br /> qeq a <br /> to become sub'ect_t Workman's Compensation laws of California." <br /> Signed <br /> ------------------------------------ -------Ownar <br /> - <br /> By- ------------------- ---- --=-----=---------------------------------- -------- -- ------ ---------------Title-- ---- ---- --- --- ------ ------ ----------- - ---- ---- <br /> (If other than owner)' 11 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ �------ -- ------ --- - -- --------------DATE.-'--/-0'7 ---------- ------------ -- <br /> DIVISION OF LAND NIL ------------------------- ---- - ------------------- <br /> ---------I-- ------- ---------DATE --------- --- -- ---- -------------- ----- <br /> ADDITIONALCOMMENTS---------- -=---------- -- ----------- -------------- - ------------------------------------------- ------------- - -------------------------- <br /> ---------------------------- --- ----------------------------------- ..... .. ---------- --------------------- <br /> ---- --- -------------------------------- ------- -------:----------------------------------------------------------------------------------- ------/* - --- ----- ----- <br /> ---------------------------- - <br /> ---------------------------------------- --------------------------- <br /> Final Inspection by:-,------ Date-:------ -- <br /> ---------- --- --- -------- <br /> ------- --- <br /> EH 13 24 SAN JO QUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />