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FOR OFFICE USE: FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT <br /> -------•---------------------- ---- p p Date ltlsN ed�.�s`-?.. <br /> (Complete in Triplicate) <br /> ............•••..-•-•.•........ ......................... This Permit Expires I 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: I <br /> JOB ADDRESS/LOCATION.��'j�oZ ......ckoir`1. . ------------------ <br /> ------------------------ - CENSUS TRACT....................-........... <br /> Owner's Name.. �,iSSQ...-.. ��GR-iC,t.:.-., ................. -- Phone'Se< '.Q-/al. <br /> i <br /> Address------ ..._. A�1-►.'�-----. lot. ...._y.... .- City... ....................Zip---= ---- <br /> Contractor's Name. t l�`l. j ST ::.: r - .License � �o ..... .Phone. .......... <br /> Installation will serve: Residence ❑ Apartmeni Hou, -D Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_ tf '{4L_ <br /> "I _j <br /> Number of living units:---. ._.------Number of drooms ..�.. Garbage Gin�E>r_-/��.:.tot'Size:�(].;�Yl�d - -- --------------------- <br /> - --- -- <br /> �. <br /> 1r <br /> Water Supply. Public System and name.- ..4TH........... - -- 13L <br /> - _.---.-Private- ❑ <br /> Character of soil to a depth of 3 feet: . Sand ❑ Silt❑ Clay ❑ Peat Sand Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Aclobe5e Fill Material._ ---- _...If yes, type...,...............--- <br /> (Plot plan, showing size of.lot, location of system-in relation to wells/ 6ildings, 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 [ } SEPTIC TANK ' Liquid Depth._.-`...................... <br /> [ } Size........:.. . .. -------- =------- ....... ...._ <br /> Capacity. .. ......... . ....Type--------- ---------Mate-rial. `------. ---:No: Compartments__.._._- •-•- ...------------- <br /> 4 <br /> Distance to nearest: Well---------------E.-------.-------------------Foundation-------.--.- ---_.-.--.'..Prop, Line............................ <br /> IN <br /> LEACHING LINE [ ] No. of Lines........ �F. L-eng.th ofFeach linea -------------_.........Total Length .................. <br /> 'D' Box..... ......Type Filter Material_'_-.._._-___----Depth.Filter Material .. ----- ---------------------- ..------- <br /> Distance to nearest: Well--------------- -----------Foundation.-- .- Property Line-•------------ ---------- <br /> ---- -.-.. <br /> f t <br /> SEEPAGE PIT [ } Depth.- .. .....Diameter-------------------Number---- -.-------.----------------- t Rock Filled Yes E] No[IWater Table Depth.-..------------- --- -----------Rack Size........................... ................... <br /> t <br /> Distance to nearest; Well.--------------- .........------Foundation-...... <br /> €€................ .Prop. Line.........--------------.... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----------=- -----'--------�--.-. .--...Date �.--.---:•.-.. .--- - ---... -- -- --- ) <br /> SepticTank (Specify q <br /> _• �� r0- 4E �-- " <br /> "ralsISE <br /> ........... <br /> Disposal Feld-(Specify Requirements). - <br /> k <br /> -------------------------------- ------------------------------------------ ------- <br /> ---------------------------------------------- - �------ . re ui �� -- �-.....---------------- <br /> -Draw existing ----- --------------- � <br /> g and required addi#ion on reverse side) <br /> I hereby certify that I have prepared this application and fhat`the- work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws,�'and..,Rules..-a"n'd Regulations of the San Joaquin local Health District, dome 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, I shall not employ any person in such manner as <br /> to become subje to Workman's Compensation laws of California." <br /> ed.....-Sign _ ----------- <br /> }------------------ Owner <br /> BY- - ------------- --- -- - ----�- - -•--- �--- �� - ---.- .......Tide. _ <br /> .. ..-....----=- <br /> F <br /> (1 h <br /> owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY N...- - DATE..---- SAV ..... ........ <br /> DIVISION OF LAND NUMBER............... . ...------ ----------------.DATE....-----------....._ <br /> ADDITIONALCOMMENTS................ ....... --------------------- -------.................--------------------------- -------- ------- <br /> ---------------------- <br /> ----------------------------- .......... .................. ...................................... ---------------------------------------------------- --------...---------- .......-----------........ <br /> --------------- <br /> --------------- . <br /> Final Inspecilan bY= ,5Date.... _`��" .7.--- ------- ------- <br /> EH 13 24 SAN.JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />