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't' 11" -, - <br /> ij, I ,=arm - <br /> ..FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE <br /> ---------- -------------- ­­­...... --------- ... Permit No...7 Z'12/ <br /> (Complete in Triplicate) <br /> Date lssued... ---.�-v- <br /> ......... This Permit Expires I Year From Date Issued <br /> ion is hereby y made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This appflicotion is made in compliance with County Or inance No. 549 and existing Rules and Regulat s: <br /> JOB ADDRESS/LOCATION <br /> ...... ...... ------­.... . .... .. .......... ......CENSUS TRACT........................... <br /> Owner' NalR --- --- -- ----- -------- <br /> ................. ....... <br /> ---- . . . . Z - Phonl\. <br /> . ... . .............. . .....Ci ------Addl . . 7 -- <br /> Contractor's Name...... . ......­............ ..........License ................... -------.Phone------- <br /> Installafion will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court El <br /> Motel E] Other-- ---------------------------- <br /> i - ' .11 a � ;L 0 0 17 <br /> Number of living units:...... ---..)Lmber of bedrooms�.'... �.Galri�ag`e Size--------- <br /> .. .... ........... ---------- -- <br /> Water SLipply; Public System cind!�name. ...................... ----­---- -- ------------------il................. ... --- ----------- ----------Private <br /> Charactlir of soil to a depth of 3 feet: Sand E] Sjltb Clay Ej Peat E] Sandy Loom E3 Clay Loam 0 <br /> Hardpan ❑ Adobe El 'Fill Material .,.If'yes, type... ------- ................... <br /> (Plot plan, showing size of lot, 1��ccitsystem in relatior <br /> ion of i' uildings, etc..mustbe placed on reverse side.). <br /> Ili to wells', buildings,-t -I' - 4. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if pq' blic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size ...............................Liquid Depth_.T.--.......... - ----- <br /> 41� Type .ee <br /> Capacit ...... - ----- Material_. ;No, Compartments..... <br /> ...mat i. ----- -- --------- <br /> pplll�w. S-/ <br /> o nearest: Prop. Line--..- ­--- - ------- <br /> Distance t rest: W. ejI.-.4!q-- -- ---- <br /> N <br /> LEACHI LINE Al No. of Lines ------------ Length of each.fil I&�, Total Length .............. <br /> D' Box-:)'�P ..Type Filter Mlateriol..Z... jr ...'-.,.Depth-� Filter Md -------------------------- <br /> Distance to nearest: Well---,370 Foundation----40--------------- ---Property Line --- --------- ..... . <br /> --------------- -- ----- <br /> SEEP, PITDepth.... -----------Diameter................ ----Nul------------------------------ Rock Filled 'Yes ❑ No <br /> Water Table Depth------------- ........­­----------------Rock Size. .................................­------- <br /> Dl '!�to nearest: Well-------------- ----------------------------Foundation...:....-.. Prop, Line........ <br /> istance --------- ...... <br /> REPAIR/.ADDITION (Prev, Sanitation Permit#........................ ------ -------------Date.-..----:---....._..-.....--.---- ----- ---- <br /> SepticTank (Specify Requirements)--.........­-------------------------------­.. I....... ----------- ------ --- .............. . . .....­.. .... <br /> .. ............... -----------­�---------............. ............................. ........... ------ -------- ........ <br /> Disposo I Field (Specify Requirements]....- ­....... .. <br /> ......... . .­­............. . . .................................... --------- ---------I------------------------------------- ....... ....................... ................. <br /> ------------------- -------------- ..............................................................................................­ ........... .........­­......... ------- <br /> J (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 /> Ordinal es, State Laws, and Rules <br /> ules and Regulations of the Son Joaquin Local Health District. Home owner or licensed agents <br /> signaturt certifies the following: <br /> certify' <br /> tin pe �a of the w for which this permit is issued, I shall not employ any person in such manner as <br /> I CoC <br /> to bec ubie: or Co e tion laws of California." <br /> Signe -- --------------- -- --- ------- -- Owner <br /> By-•-------- ............ .. ................... <br /> ------------ ...................................... Title ................... ........ ------------------------- <br /> (if other than owner) <br /> I. FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------I' . ..... . ................ ......... .. ..... .......... ..................... -DATE .. ....-------- ........ ......­ <br /> ... . .......... . --- I ---- <br /> DIVISION OF LAND NUMBER.---- A. :­­......... ...................DATE.-- -----------------I- ----- ------------ <br /> ADDIT16NAL COMMENTS ---- --- ------------- ...... ... ---------------- <br /> i�-­--- ".4......... -------------------------- <br /> -47-7....75-�� ...... �2�..... <br /> --------------I �...... ...... . --- --------- - - --- -- ------ --- --- <br /> 4�7 <br /> ............. ....... ...... <br /> ---- --- -----I---------------­ ........ ------------------------- --------- ----- ---------­------------------­ <br /> ------------4-------------------- --- ... .......... ..................... -- ---------- <br /> ------ --------------- .......... <br /> Final 14-113 ion by:........ ---- -- - --------------- <br /> s eci ------ ------------ -------- ------ <br /> IEH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677f l�7/76 3M <br />