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FOR OFFICE USE: <br /> FOR OFFICE USE: <br /> APPLICATION-FOR SANITATION PERMIT <br /> ­ 4 1.,— - 4 s <br /> ............... Permit No...7 . ........ <br /> ........... Momplete"InxTriplicate) <br /> ..............._..---.....--•,...!�C�* .. 7f <br /> ............... issued....g77Z.2 <br /> Date -------- <br /> . <br /> .............. ­......... ..... This Permlt ftplres I Year From Date Issued <br /> .. <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 /> ........................CENSUS-TRACT..........---------------------- - <br /> JOB,ADDRESS/LOCATIO ........ . .... .. <br /> Owner's Name. . . ....... ----------- <br /> City._ <br /> ............... <br /> ......... .. <br /> ------------- PY <br /> Address.... <br /> ------------ ......Lice <br /> Co�ntr'actor's Name.._...... nse Phone_ <br /> Installation will serve., ance Residi me <br /> pa t nt House.t Commercial,[D iTrailer Court L <br /> r <br /> Motel Other <br /> ........... <br /> ........ <br /> Number of living units:, Grinder__*.*.:..._•..-Lot Ize-.- <br /> .. <br /> kil <br /> .................Private <br /> Water Supply- Public System an'd�Kame.... -------- ........ .............. ................. <br /> ......................... <br /> Character of soil to a depth of 3 feet- Sand Q' Silt C] 'Clay F-1 Peat Sandy Loam El Clay Loom <br /> HardpanAdobe.[) Fill Material...... <br /> If- .. ...... <br /> type........... <br /> (Plot plq' n, showing size of lot, location of systelm in relation to wells,buildings,etc.must be placed on re-;e!rse side.) <br /> 1 <br /> NEW -INSTALLATION:._ [No' 'k or seepage !FR mitted if public se'w__e�,i ilable'w'ithin 200 feet,]septic tan permitted S <br /> Size------------!_........ ------------- -------- <br /> PACKAGE TREATMENT- [-] SEPTIC TANK [11 &Z, Liquid Depth...... ------ <br /> ---------- ............ <br /> Capacity!::... :_.:Type ............LE-------Material.......... ------........Na <br /> ..........:----------_._':Foundation_'_.. <br /> Distance.to.nearest- Well, ._ <br /> ------I.......... Total' Length....... <br /> LEACHING LINE No. of,Lines.:.......__t... pf each line..:'----_T. <br /> ateriaL...,........ <br /> .'D' Box-----..---...Type Filter Material j....................Depth FilterM ........................... <br /> e ..... Property Line._._.__. <br /> --------------- <br /> Distance to nearest: Well. .Foundation....._ <br /> SEEPAGE PIT Depth....1-----------Diameter....................�tNumber---- ------ Rock Filled Yes:E] No7 <br /> . ......Rock Size'--.:........ ------------........... <br /> aDepth-.. -.-_- --.. .. ...... -------- ...... <br /> W r"T ble" " <br /> t Distance to Prop. �ine..*___ <br /> ......................Foundation:: " <br /> ! . ... . - -- <br /> REPAIR/ADDITION (Prev:Sanitation Permit#..... .... ............... ............jDate...... <br /> Septic Tank (Specify Requirements)---._----- -------- <br /> ............ <br /> ------ - - <br /> Disposal Field (Specify-ft ---- -- -... <br /> �7. <br /> ......................... ......... <br /> ................ <br /> ................. ...... <br /> .................. <br /> .......... --------- .................... <br /> j,tbraw*existing and 1equirecl addition:iriweirse siae <br /> :1 hereby codify that I have prepaired,this-application-and that the.'Work willfbe r�one2 <br /> in Nduordance with Son 4a'acivin County <br /> Ordinances, State. Laws, and Rules:and Regulations of the Seto Joaquin Local Health Dish4h Home owner or licensed <br /> agents <br /> signature codifies the Qlawinjl.' <br /> ­I comfy that in 'the performance of,the work'for*Wich jhjj'Pijim1t'is issued; I SLI no`t.:eMpIoyV any person in such manner as <br /> to bocome, 0Ct workMan* C61Tponsation'.1aws of California." I& <br /> Signed.. AtZ ...........Ownor <br /> T' aV--7, <br /> ------------ ------:7---------- <br /> BY......—............ <br /> (if other than rier) <br /> FOR DEPARTMENT AISA QMLY <br /> APPLICATION ACCEPTED�8"Y-� ...........�W_Z41 <br /> -.7 ..... <br /> ................DATE. <br /> DIVISION OF LAND NUMBER,!�...... ............. . <br /> .. ............. <br /> ADDITIONAL COMMENTS............................. ........ ....... ....... ,..........---••----.... ---------- . <br /> -------------- <br /> .............. .......... <br /> ................... ........ ........ ................. ............. ..... ............... ------------------ -------­---­ <br /> __:------------------------- <br /> ........................ --------...... -------7------------ ----I......­....... <br /> ---------- ...... <br /> ------------- ....... <br /> ............... ................ ............ ...•--•- ---- -------------------------------------------&=q --- <br /> Date--------- <br /> ---------- <br /> Final Ins -bytz�­,t;z,, <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV,7/76 3M <br /> 4 <br />