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FOR OFFICE USE, ✓ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.75.�V/J-57 <br /> ..................•------ ------ - ...--- ------••----- k. n `. Date Issued.J,,2. <br /> .............. ................................ This Permit Expires 1 Year From 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 com liance with CountyOr �fTa- a No. 549 and existin Rules and Regulations; <br /> U <br /> JOS ADDRESS/LOCATION..... .... --........ _.- -z ..:_.CENSUS TRACT.......................... .. <br /> Owner's Name. - .. G- one <br /> lP �j - --- ••-.: .... -.Ph <br /> Address..... ............ -- ll// �� . <br /> C7 <br /> n. '� . r..._.....City.... � - -- ------- --Z1P-.._.. <br /> -InstContractor's Nam . .. .. ----�------ - --- ------- --------License #__3 /Phone.. --------------- <br /> Installation <br /> allation will serve: Residence ® Apartment House ❑ Commercial [] Trailer Court ❑ <br /> Motel ❑ Other..................... <br /> ' Number of living units:.____.. Number of bedrooms. Garbage Grinder ` ...Lot Size=.._.. .. <br /> Water Supply: Public System and names:...-.. ..:'= :.. Private [�-r <br /> P ❑ ❑ ❑ Y ❑ 4 y.Loom ❑ <br /> Character of sail to a.depth of 3 feet: Sand Si Clay ' Peat type <br /> Loam Cla L , <br /> P ❑ <br /> Hardpan Adobe Fill Material . .... ....If es, t e--------------- <br /> I (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 /> PACKAGE TREATMENT [� j SEPTIC TANK [ Size......= .............:--------------------Liquid Depth...-:.:.-.--.-------....... <br /> ' Capacity. ------.-TYPe ---------- - -------- Material..------. ----.....----...No. Compartments..... ................. <br /> Distance to nearest; Well--------------------- -- ----*...._._.....Foundation_.. .... ... ....Prop. Line....................... <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 PIT [ ] Depth.- ............Diameter_.:-................Number_._. <br /> ------•-•------------------- Rock Filled Yes ❑ No <br /> Water Table Depth----------------................................. -----Rock Size ------------------ ........... <br /> Distance to nearest; Well--------------------------..........--......Foundation.._ --------------_-------Prop. Line--------.......---------._-- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------- =----------------- ---- ----------Date---------:-.--------.---.........--------------} <br /> Septic Tank [Specify Requirements) .:_ '_° -��' __ <br /> Disposal ield (Spe 'fy Requirements)...............:: � X �S' <br /> ... <br /> �' ............ - -- ------------------ ................ <br /> - --------------------------------------_------- ----------------------------- :. <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 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; <br /> t <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed =------- ......:......Owner <br /> By.. .. ....... <br /> Title.. ....... <br /> (If other than owner) <br /> FOR EPART NT USE ONLY <br /> DATE --..f . ..l.�..7 ..... <br /> APPLICATION ACCEPTED BY...... .......... <br /> DIVISION OF LAND NUMBER.-- -- -- --------.DATE ------ ------------------- -- --- -- <br /> ADDITIONAL COMMENTS-- ------------------------------------- <br /> ------------------ <br /> ----------------- ------------------------------ C��k `�'� ........ -•------- <br /> -•---------- -------- <br /> --------- -- - ..------------------------••--•--- ------ - ----------------------------------------- <br /> Final Inspection by:........ -. C.'. �_/.}'}...Y Date.- g..�- <br /> s EH 1324 ✓ :z;� - - - - <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7/76 3M <br />