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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 7�vis <br /> ------------- -------------- ----- ------ --------- Permit <br /> (Comp(ete in Triplicate) <br /> -------------------------------------- Date Issued_-- -" --"�� <br /> ----------------- This Permit Expires 1 Year From Date Issued <br /> ,_„Application is� hereby made fo""th`e Son•Jooquin_Local Health District for a permit to construct and install the work herein described. <br /> This applicatio n•is,made._in..compliance with County Ordinann-No-549-and-exist ng.Rules and Regulations: <br /> 77 <br /> RE� <br /> JOB�ADD /ILCitATI N--- -�--�`� -- - - ------- e� /� ''____ ~-CENSUS TRACT----------- -01 <br /> - <br /> f / ------Phone <br /> fOwnersName. [- {_Q - <br /> Address- -� ----- City Zip <br /> Contractor's Name __ _ r ,r�•4��-�--�. License #"R47- r�'-'l` Phone__. - -2-� <br /> Installation will serve: Residence ❑ Apartment Hciuse.❑ Co mercial ❑ Trailer-Co:,ft'o <br /> Motel ❑ Other---fr - -------------------- <br /> ,/1 <br /> ----- -----='---- �` <br /> Number of livingunits:___ __ Number of bedroom`s��-".Ga br age Grinder "Lot Size--- 7 -� --�---- ".------ <br /> Water Supply: Public System and nome---- ____ _._______Private ] <br /> -------------- - <br /> Character of soil to a depth of 3 feet: Sand ❑ S lt'❑ Clay ❑"Peat❑ Sandy oam Clay Loam ❑ <br /> Hardpan ❑ Adobe '^ ill'Matericil-- .--------If yes, t p --------------�,------------- <br /> - <br /> (Plot plan, showing size of lot, location of systein relation to wells, bu}I-81 gs, etc.•m_ust be placed on reverse side.) <br /> m" W <br /> NEW INSTALLATION: (No septic tank or seepage"pit permitted if public seweFJs available within 200 feet,J <br /> PACKACfiREP-TMENT [ I--'SEPTIC TANKS -'�-�---maize �t-�,����Q � Liquid Depth---- <br /> -TMENT [ <br /> Compartments <br /> Capacity/, 0 �� Matarial- p r <br /> r` l �� <br /> Distance to nearest: WelL _ -<-------- -----------------FoudaXop.� ..._. L'r�.p#Line--- ----------;--- <br /> . � <br /> LEACHING LINE No. of Lines ---------'-----.Len h L— rine.- - -----------.Total Length------8Q----------------------+" <br /> 'D' Box. Type Filter Material -.Depth Filter Material.-- -- ----- 1---- <br /> - 'S <br /> f f <br /> + Distance to nearest:Well __---_ l__- ----------- Property Line_____ <br /> Foundation i <br /> pp--� --- <br /> Rock F led a No ❑ <br /> SEEPAGE PIT Depthp tl.____"._piameter. __------Number- -- - R it Y <br /> i >' I <br /> t Water Table Depth ____��-- --- -----------Rock Size__. yd t i <br /> n - _-- p. <br /> Distance to nearest: Well. .------------------------ Foudatio __`r_"°-__�.Pro Line --_- ------ <br /> ---------(---. <br /> REPAIR/ADDITION (Prev. Sanitation PerTni7-#--�--- - ---- ----------- <br /> ------ -----.Date------------------------------------------ <br /> - <br /> Septic Tank (Specify Requirements)-------------__..___ <br /> - <br /> Disposal Field (Specify Requirements)---------------------- ---- `----------- ----------------`"" <br /> ------------- ------------------------------------- ------- <br /> ______._.--f <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 with San Joaquin County' <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local HecdtkLDistrict. Home owner or licensed agents <br /> signature certifies the foliowing: 1 <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 subject to Workman's Compens6laws of California." rLAREKN SEPTIC & SEWER SERVICE i <br /> Signed - - -----------------------------Owner 263 So`Po $tackton, Calif. 95245 r <br /> ? T's LiC,f 2 <br /> _00 <br /> f Ph.4v3-3 s9 CIIr,.IL'Cke 67I77 <br /> BY----- e <br /> --------Title--------------------�--------------------- ----------- ------------- l <br /> ( (1f other than o J ,iU ' <br /> FOR DEPARTMENT USE ONLY ✓ <br /> APPLICATION ACCEPTED BY-------- ------------- ------------------------ - ---------DATE.-'Y------J7- -------------------' --- <br /> DIVISIONOF LAND NUMBER."-- -------------- ----------------------------------------------------- DATE.-------------------- ----------- <br /> ADDITIONAL <br /> ---------ADDITIONAL COMMENTS------ -------- ate.+ -Al------------- '0� ----------------------------------- <br /> j <br /> ^----3-------- - ----------------------------- ------------- -- --- <br /> ` ------------ --------------- -------------------- ---------- ---------- ----------------- -- <br /> � - `-F----------------'--------_-_----�---�_- <br /> --------- <br /> --- <br /> ____----'t_'----_'_.--_. --------------------------------------------------------------- <br /> ----------------------------- <br /> ---------------- ----------- <br /> -- -- --- ----------- - ---__'-- -- <br /> ____ _ _-__________ __ _._ __________ _________________________________________ <br /> Final Inspection b - ---- ------- ------ ---Dater _— ----------------------- <br /> EK 13 sa 'T�' ' �' SAN JOAQUIN LOCAL HEALTH DISTRICT t F&5 21677 REV. 7/76 3M <br />