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[ FOR-OFFICE USE: .I FOR OFFICE USE: <br /> - APPLICATION FOR SANITATION PERMIT <br /> Permit No. 711a� <br /> (Complete in Triplicate) .......... <br /> ..............7�' <br /> I <br /> ......................... ....................... This Permit Expires 1 Year From Date Issued Date issued-1 <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_... - -,. ......... a- " CENSUS TRACT <br /> t <br /> Owner's Name..�. 4 * ` hone <br /> Address-..`-- �.'l - cJ�J�c?�-�3� < __ tt <br /> Contractor's Name--------------------- -----.... License # `' - Phone...-_..:.... <br /> } ..... ......... <br /> Installation will serve: Residence nK Apartment House ❑ Commercial ❑ , Trailer Court ❑ <br /> Motel ❑ Other-------------------- ------------------- <br /> i Number of living units;._.........I....Number of l edrooms-:_.- V;_cZ;arbage Grinder---(nP-Lot Size............. -.c_^_4QL_::2_1_____24_--- . <br /> Water Supply: Public System and name_. .----- -`------ -- ------------•------ ----------------------------- - --- ------------ ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑:.Silt❑ Clay I � Peat❑ Sandy Loam E] Clay Loam El <br /> a`. Hardpan ❑ Adobe ❑,Fill Material.........._.lf 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 [ ] SEPTIC TANK [ ] "'Size. 1'le w_.- - q�.....- Liquid Depth...::-hp..._.......... <br /> ..- <br /> Capacity..\p.0 C-_.---.Type.. ,.Material o. Compartments----------------------------- <br /> Distance to nearest: INell...`7.�_l__... <br /> t --- -- ---Foundation-•-���+� - Prop. Line---x.0.(7......-........ <br /> LEACHING LINE <br /> [ ]' No. of Lines........... .............Length of;each line...... '-— . . Total Length _. \S.C.7--- --------------------- <br /> % <br /> --..---..-------- - � <br /> 'D' Box.�..I.Type Filter Material c3 ..Depth Filter Mdterial... .. .. .............................................. <br /> I Distance to nearest: Well..:. ---: .Foundation---- <br /> --------------Property Line--------- .-.e::........... <br /> Number.. ❑ <br /> ..SEEPAGE PIT— [ ] Depth...�.�_.....Diameter. O-_lC-- �j----------------------- Rock Filled Yes Nb <br /> V M <br /> � V," Water Table Depth.__....------_-s.............�--------------------------Roc k Size <br /> t r We . .._. Bat PropLine......- <br /> ',b4tance tone rest, <br /> REPAIR/ADDITION [Prev. Sanitation Permit#-----------r---=-: .. ------:-.-.Date.-,--------- ..... ..........................} <br /> Septic Tank(Specify Requirements)__ <br /> I <br /> i fA <br /> Disposal Field (Specify Requirements)...... ­....... --- --------- ----- .............. -... .. = --------------------- --------------.--- - <br /> . <br /> ---•------------ -- i-- <br /> (Draw existing and required addition on <br /> 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 /> Ordinances State Laws and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: i t i <br /> "I certifythat in the l <br /> performance of the work for which this permit is issued, I shall not employ any person in such manner as j <br /> to become subject to Wo km Compensation laws of California." <br /> Signed ..-_ ..fill — .........---• ----- --- - Owner <br /> By--------=---------------------- ------------------- ------- ---- ---------------------------------------- -jA <br /> - <br /> [If other than owner) <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-,------- --`r�-- ------------------------------------------------------------------ --------DATE .---�Z` t�> ..... <br /> DIVISION OF LAND NUMBER_............� - {DATE. <br /> ADDITIONALCOMMENTS............... A. . •-• . ...-----....------------....---•----------...---=-----•. •..... --------f...------------------------------------ --- <br /> ------------------------ ....... ................... ............. ------ <br /> --------------------------------------- -- ---- - ............----------------- ---••---------------------------------- - ------------ --------­­-------- .....--------....................... <br /> ----------- ----------------------- -----------------I <br /> - <br /> Inspian b Final i . <br /> EH 13 24SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2F577 REV. 7/76 3M <br /> i <br /> s <br />