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FOR OFFICE USE: FOR OFFICE USE: <br /> PPLICATION FOR SANITATION PERMIT 7], G <br /> ------------- ---------------------- (Complete in Triplicate) <br /> Permito------------­---­---- <br /> /� � <br /> Date Issued.__f"...._.....-7 <br /> --------------_______________________________________ This Permit Expires 1 Year From Date Issued <br /> ,^.-Iplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> — -----------CENSUS TRACT -- <br /> JOB ADDRESS/LOCA"TIIOON-- E 7�`�. L,'-------t -`- �- <br /> ,vner's Name-_ _ _ Phone-------------------------- <br /> " 3 p ------- - ------------ City----Address - ne>ntractor's Name----- - -- --- - ---- - ---- - - -- . ------ -----------License #_3� 2Ph0 ) I 1 <br /> stallation will serve: Residence 9T_*" Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--------------`-`------- ------11---------------- <br /> ember of living units:-------'------..Number of bedrooms_.-3-__Garbage Grinder------------Lot Size. ,__ ---S.-_ 7___ 3 J <br /> --- - <br /> ater Supply: Public System and name.-•------------------------- ---------------- ------- ------------_--- ---------------_ ------ ---------------------------.Private <br /> ('haracter of soil to a depth of 3 feet: Sand E] Silt E] Clay E] Peat E] Sandy Loam ❑ Clay Loam E]Hardpan � Adobe ❑ Fill Material-------..-:_If yes, type________________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> EW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is available within 200 feet,) <br /> �CKAGE TREATMENT [ ] SEPTIC TANK [� Size_ __l -:/4-5_"�- -. -r--------------Liquid Depth ____-----____-______ <br /> Capacity_.J�-O.a_____-_Type - ---- -----------__1Maaterial -Gam_----No. Compartments.-----_�--------------- <br /> -----` <br /> Distance to nearest: Well--.-._--....� -f]"F_ -----------Foundation-_____ Prop. <br /> -_ � Ji <br /> Line___- <br /> No. of Lines-_-____ 3 ___ . _-__-__.Length of each line._____4- .tatet <br /> Total LenLEACHING LINE 6th <br /> .__--_-_-_-.-_-_-_-.-. <br /> .-_--_�-__ <br /> 'D' Box - -- --TYPe Filter Material---------5K.De ,h Fileal._----.. _________-___.__..____-- -- CDistanceto nea est: Well------- Foundation____-_-_ Property Line__ ----- ___ <br /> - m ____-___t j______________ RockFilled Yes No ❑SEEPAGE PIT Depth....Z_ _Diameter-_--33 Nuber <br /> Water Table Depth------------ - -- .Rock Size-- - <br /> - <br /> _ <br /> _. <br /> x- 3 ------------------- <br /> Distance to nearest: Well -_._.__________._Foundation__.%�-_ - Prop. Line_.____. _ _. <br /> Sanitation Permit#_________________________ ----------- <br /> .PAIR/ADDITION (Prev. -----.Date--------- --- ------- -------------------) <br /> epticTank (Specify Requirements) --------------------- - ---------------------------------------------------------------------------------------------------- ---------------------------- <br /> DisposalField (Specify Requirements)----------- ---------- ---------- ------ --------------------------------------------------------------- --------------- ------------------------------ <br /> -1--------------------------------------------------------------- <br /> --------------------------------•----------------------------------------------------------- ----------- ------------------------------------------------------------------------------------------- --------- .:------------------------- <br /> ---------------------------------------------------------- ---- .-._--------------------- --------- -------------- ----------------------------------------- --- --------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Jrdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> 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 /> .a become subject to Wo- man Compensation laws of California." <br /> Signed------------- --------------- Owner _ <br /> ly----------------------------------" <br /> � ��- �G .- ' le-��.. -c.- � --- -------------------------------- <br /> of er than owner) <br /> F R DEPARTPKENT USE ONLY <br /> kPPLICATION ACCEPTED BY---------CC. . ------ ------ - ----------------- ----------------------------------- _9-_DATE ---- - <br /> DIVISIONOF LAND NUMBER-- ---- ----------------------------------- ---------------------------------------------------------DATE---...------------------------------------------ <br /> %DDITIONAL COMMENTS----- ---- ---------------------------------------------_----- -- ------------------------------------------------------------------------------------------------ <br /> ---------------------------------- ------ - ---- ------------------------------------------------ ---------------------------------------------------------------------------------- -----------_- ------- <br /> ----------- ------ ------- -------------------------------- . --- --------------------------------------------------------------------- --------------------------------------------------------------------- <br /> -- ------ - -- ---•------------------ ------------ ---- - ------ - J --- -------------------------------- ---------- <br /> sinal Inspection by: Date � <br /> cH 13 24SAN JOAQUIN LO AL HEALTH DISTRICT F&S 21677 REV. 7/76 3N <br />