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� c <br /> FOR OFFICE USE. �i FOR OFFICE~ USE: <br /> APPL CITATION FOR SANITATION PERMIT <br /> ---------I——................ f/ <br /> (Complete in Triplicate) Permit No.�7-�-::j.A.- <br /> ------------------------------------- This Permit Expires 1 Year From Date Issued 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 /> JOB ADDRESS/LOCATION. . ...�...... +. - _�f...... ------: ..---.,CENSUS TRACT....-----•- <br /> ff <br /> Owner's Name . . <br /> "' . ..`- . ._ .. .' }.. w .. c... Phone. .tl�..'_-_-.- J--...._ � <br /> Address..----...... ep_.- - l . __j...----- -- Cit ...........zip.......... <br /> Contractor's Name.... „ . .. -- . .._ -- . . s <br /> .... . . <br /> Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court E]Votel ❑ Other --- -- --- -- ............ <br /> Number of living units:......-__:.-.--Number of bedrooms... Garbage Grinder---.--------Lot Size----- .. c .. .. . <br /> Water Supply: Public System and name--- -- ------------ - ......... ..-- ------ --.._-Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam E] <br /> 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 /> NEW INSTALLATION. (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> I PACKAGE TREATMENT <br /> E 1 SEPTIC TANK ( ] ~ Size------- ----- --- - -------------------------..------.- Liquid Depth.................. <br /> Capacity ..........:..TYPe.......................Material------------------------::No. Compartments--- ---...y--.----- <br /> Distance to nearest: Well.`...................... ....-.--...-------Foundation-.:....... . ......... . Prop. Line---.-_-----------..--_--I <br /> LEACHING LINE ( ] No, of Lines ................Length of each line ----.--------------------... Total Length ................................ <br /> 'D' Box---- Type Filter Material....................Depth Filter Material....................-._...... ---------- <br /> Distance to nearest: Well......................... ..Foundation-------------------_------.Property Line.--"---_---- ---_-------__-- <br /> SEEPAGE <br /> --..__..-.... _--SEEPAGE PIT { ] Depth_..----..... -Diameter- --------------Number---..-----..--------_..._....... Rock Filled Yes ❑ No <br /> 4 <br /> Water Table Depth---------------------------- .........:.-.Rock Size.-------- ................... ....---......-- <br /> Distance to nearest: Well..................___.--------------------Foundation_- --------- _..._.Prop. Line._-..- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#........................ ----------------Dote....................... _----.-----------.----] <br /> Septic Tank (Specify Requirements)...:..... ..... %;---------------------------------- .......... <br /> Disposal Field (Specify Requirements]... - .-..` -: _. �-- tt�'" ._ - t1*1. "s `*- "°-It' <br /> k' <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 Sari 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 c that in th performance of the work for which this permit is issued. I shall not employ any person in such manner as <br /> to com subje t't W r m s C p satioa laws of California." <br /> Signed.._.__. Ownex <br /> ...... ...................... <br /> By-------------------- .......................... --- ---- Title........ --------- -- <br /> (If other than owner) <br /> POR DEPARTMENT USE ONLY <br /> s APPLICATION ACCEPTED BY----- `.,+.. ---- . --------DATE .c.. ._7- --_- ------_------------ <br /> DIVISION <br /> ----- --- --------DIVISION OF LAND NUMBER------------- ----------------- DATE"....---...._-...--. <br /> ADDITIONAL COMMENTS ........ .... . <br /> .... <br /> i Final•Insp>rcf on b -- -------- Date.- � --7...........- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br /> t <br />