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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............ ........--- .............. ...... .. Permit No.-7_947q_/_ <br /> (Complete in Triplicated <br /> -- ­ ................ ---------- .-- -- <br /> Date Issued.lD..!f/.--..� <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 compliance with CountG00rd' ancNo. 549 and existing Rules and Regulations: <br /> dG <br /> JOB ADDRESS/LOCATION <br /> AJTION <br /> CENSUS oTnReA--CGT..-G...:r-...: <br /> Owner's Name................... ....... ------- ....... .............-......... <br /> ? � d zip: . -... ------. - -...Address.... : ..... G3 :. <br /> .t .. - . <br /> Contractor's <br /> Name ....... ......... .... .........License # ----- ........._Phone.--... ......... ------ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Number of I Motel E] Other-,....--------------- <br /> ------ --------- <br /> living units; of bedrooms_.-.-- ---.Garbage Grinder............Lot Size.......- - .----1 3 <br /> Water Supply: Public System and name----' 4-.; :. r''-.. .................. -- ----- ---- --- -------- •.:-------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑. Adobe ❑ Fill Material....-.......If 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,] W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I I Size-----y.c7- _.._.Liquid Depth ............. - -------- <br /> Capacity- ' ( ype... ... . f LA <br /> �"--triol...... .---- ..._...No. Compartments_.. - --- -------- <br /> 1• 70 ;,f� <br /> Distance to near9st:.Well..----- _- w-------------------Foundation..........-. _ ..........Prop. Line---------------------- --- <br /> LEACHING LINE [ ] No. of Lines .._.. _--.Length of each line _... _r .-�-.- - -.------ Total Length...... . .. ....... <br /> 'D' Box............Type Filter Material.14-s. ..---- DeptKFilter Material...{-!- ................ ------ <br /> Distance to nearest: Well................_,...--....Foundation...------------ ------..-... Property Line-----------------------.-----••-•- <br /> /a, <br /> SEEPAGE PIT ] Depth.--fn. —n....Diameter....-�,i .Number.... - ------------- Rock FilEed Yes ❑ No ❑ <br /> .,> <br /> WaterTable Depth --------•- •-------- ----------••----------------.Rock Size.: ........................................... <br /> Distance to nearest: Well...--.t_: �- ------Foundation.__......--- ......Prop. Line................... <br /> .1-----. <br /> REPAIR/ADDITIOW'(Prey. Sanitation Permit#-----------------------•----•--•-- ------- --.-._.Date- -----------------...--..........--------.---] <br /> Septic Tank,(Specify Requirements)............... ... . ............... - -----...-- ------ -----.....-- - ------------------------------------------------------------------- ----- - <br /> Disposal Field (Specify Requirements)_--- ---------------- ............................................-.. <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 Coun <br /> Ordinances, State taws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agent <br /> signature certifies the following: <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 su Le-ct to Workman' compensation laws of California." <br /> Signed_......- .....! r= �.... .,_r... -- . Owner r <br /> C IC�IJL✓� <br /> ------ ------- ... ---------------Tit e__._.... --. ..-.----------------------- . <br /> (If other than owner) <br /> FOR EPARTM T USE ONLY <br /> .:�.� - ----DATE ..--..._ .1....__ ...j.-.. ; <br /> APPLICATION ACCEPTED BY----.... :.- y ---... ..,. ------------------------- <br /> DIVISION OF LAND NUMBER.................. :.... / ---_--- ---------- ................ <br /> DATE. <br /> ADDITIONAL COMMENTS... ... "• -----�.. <br /> -------------------•-- . ................................ - -- ....... ............ <br /> ............................----------------------•----....------ -----------------.- --- --... ----- ----- --------------------- ------------------ ---------------..............-----..------------ <br /> Finallnspecnon by�-----.------------....... ............ ----------------------------------Date....-------- ---................................. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/76 3M <br />