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FOR'OFFICE`USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �J <br /> ...... ......... <br /> I� (Complete in Triplicate) Permit <br /> II Date Issued.s5-. 3/' <br /> .---....................... This Permit Expires 1 Year From Date Issued <br /> :F <br /> IM <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 cornplionce with County Ordinance No. 549 and existing Rules and Regulations.. <br /> l 2ZZN <br /> JOB ADDRESS/LOCATION .. ........................ �" �/ L�.....-11_> ... --------- CENSUS TRACT...----------------------- cJ <br /> r/:4...:.- --•--- Phone:--qq 3.�' <br /> Owners°Name �-L ..' "....... O , <br /> � _-Zip­� <br /> = ....:Address- . . . . .. .---...--a-- --�.. . <br /> Contractor's Name....... ... . <br /> License <br /> Installation will serve: Residence ❑ ' Apartment House ❑ Commercial ❑ Trailer Court ❑ �' <br /> Motel ❑ Other.. flc%-... ' L' Tld`�l <br /> Number of living units;...............!.Number of bedrooms:_...-.-...Garbage Grinder-------------Lot Size................-. . a.....,........... <br /> Water Supply: Public System and.name-- ----- •--------------------_----------- ------ ------------------------Private <br /> i <br /> Character of soil to a depth of 3;feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ;M Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material .. .....If yes, type................................ <br /> (Plot plan, showing size of lot, I M cation of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tankor seepage pit permitted if public sewer is available within 200 feet) <br /> y,; _ :.r--- s �-• ! � <br /> PACKAGE TREATMENT [ ] SEPTIC TANK . [.r];'� Size V.. -�1��.-x--6 -------------•------ .Liquid Depth.._J.�...-..--- --- 1 <br /> _-- <br /> ii « . : <br /> Capaety TYPe i�C. Material No. Compartments . <br /> Distance to nearest: Well-'—// -_-._ ........................Foundation.-.------- . ......Prop. Line-------- <br /> --.... --....`i-t <br /> LEACHING LINE [ ] No, of iLines.._....f ....:........Length of each line..-�D._..................Total Length .......9 .................. -- <br /> 4 yc �i <br /> 'D' Boz...�.--...type Filter Material. - ... .�L...Depth Filter Material......- �1.--------------------------- ------------------- --- <br /> Distance to nearest: Well ??------------- Foundation----- -------------- --Property Line..................... <br /> SEEPAGE PIT [ ]..,. Depth.... .........Diameter------------_------Number -_-------_------------- ---- Rock Filled Yes EJ No <br /> Water .Table Depth......... .................. ;----- ---Rock Size.. . -------. ------------`----------{... <br /> I _ f, <br /> Distanoe to nearest: Well..................... °"- '-->_--- -----.Foundation...............- - Prop. Line,--------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------_----------------- ------ --- ----------Date----•------- - ----- ------- <br /> Septic <br /> '-_.. - --- =Septic Tank (Specify Requirements)---- -----------------• --------------------- . .... _- --------••--••-•---------•°------- - - ------------------ ---- ------------ <br /> I Disposal Field (Specify Requirements).... ... - <br /> s <br /> .... ._ ' <br /> I! F - --------------Y ..--- <br /> (Draw existing and required addition on reverse side[ 41w <br />! I hereby certify that I have prepared this application and that the work will be done in accordance with San .foaq Iu County <br /> 4 Ordinances, State Laws, andikRules 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject t Wor aIn s ompensation laws of California." <br /> I <br /> Signed..:.. ----------Owner <br /> BY I� Title .......... ..... .... ------ ... -- <br /> ( . ) ---- ----------- ! <br /> If other than owner i <br /> T FORD ItTME T pNLY . . <br /> /-.-..... <br /> APPLICATION ACCEPTED BY---�E-.. .-. DATE -----..-..- -. -� <br /> DIVISION OF LAND NUMBER -A - DATE---- ------------- -------- ........ <br /> ADDITIONAL COMMENTS 11 ....... •- --- ..-------•------- .... ------------ ----------------------- ......... - ..... <br /> ------------------------------------------ - ----i- -- . ....-..-...---------•----------.........- -------- ---• •--- -- -------- ._.. <br /> --------------------- . ............... ------------------- <br /> ---• --------_- ---------- <br /> IM <br /> „i. T - <br /> Final Inspect�an b Date ./_�-. 7 <br /> Y---- - <br /> r EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT fS5 21677 REV. 7/76 3M <br />