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FOR OFFICE USE; <br /> PP.( FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ' <br /> (Complete in Triplicate) Permit N o2a-*��L�_. 6 <br /> .................. ......... ......................... ­. ,, <br /> Date-1 ssu.ed_.,�_,P-Kn <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 complia ce with County Ordinance No. 549 and existing Rules and Regulations; <br /> JOB ADDRESS/LOCATION. --- ------ ---------------CENSUS TRACT..----_----------...- <br /> Owner's Name... ................... ....................... ...... . ------------ --- ......--..:-.-:..-• <br /> Address... -----_---- .................... . .... ---------- <br /> Contractor s Name..68a.kZ_/'1.C,/C/----- C_---.....License ..Phone <br /> Installation will serve: Residence E] Apartment House T,] Commercial E] Trailer Court E] <br /> Motel ❑ Other.-.. &V-14_1......................... <br /> Number of Living units:...../........Number of bedrooms 4..- , Garbage Grinder_/V,0...Lot Size.,5QX._/_ ............. <br /> Water Supply: Public System and name 64k...4)4&--—-------- _-------------------- ---------- ........ -----------------------------Private El <br /> El El <br /> Character of soil to a depth of 3 feet: Sand F) SiltE] ClayEl Peat ❑ Sandy Loom ❑ Clay Loam <br /> Hardpan F1 AdobeJA_ 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,) <br /> PACKAGE TREATMENT SEPTIC TANK Size." . ..... ..... -------­----------------------------- ----Liquid Depth.------.-.------------. <br /> Capacity.... ...Type-----------------------Mot5rial...............----'-.....No. Compartments..---.--------- ------ <br /> Distance to nearest: Well.. .... ......................... --------.Foundation..---... -- .... .......Prop. Line.................... <br /> LEACHING LINE No. of Lines..................."".-...-..Length of each line--------------------_--------Total Length . ..................... <br /> Y <br /> 'D' Box............Type Filter'Material--------------- ..- Depth Filter Material...... -----------_--1------ ------------ ........... <br /> Distance to nearest:.,Well... -------------------Foundation.--------.-----------I_......Property Line.----_------ _- -------_--------- <br /> SEEPAGE PIT Depth.......... .....Diamet6r..---------- ----- Number..-..-----.-----------:' ------- Rock Filled Yes E) Noo <br /> WaterTable Depth-------- ------------------------- --------------.Rock ........ ........I.......__--------- <br /> Distance to nearest: Well---.----- . ---... ------. - - -------Foundation......----...... ........Prop. Line-------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--- -------------------------- - --------------.Date.... ............. <br /> ----- <br /> Septic Tank (Specify Requirements)----. .........40 ....41-ve- :-Ieua... ----- <br /> Disposal Field (Specify Requirements)..cZ5!E�-0-t- ..... .......... ---------------- ........... ---------- --- ------ ------------------ ------ - ................ ..... <br /> p. <br /> ----------------------------------------------- ------ ......I------------------­­­------- ------ -----------------.............................­......... .............. ----------- <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 Son Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed agents <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 subject to Workman's Compensation laws of California." <br /> Signed------ ------------_- ....... ---- Owner <br /> ...-.Title--------- ---------------- .............. ------------------ ------- <br /> ------ ----- <br /> By......... .................�e ------- <br /> (if other than owner) <br /> FOR DEPATMENT USE ONLY <br /> 7/? 715 <br /> -33 . ............ <br /> - - --- ----------- - -------- <br /> APPLICATION ACCEPTED 8Y___,AW4_4404_�X----- -------------- ------------- E., <br /> ---------- <br /> DIVISION OF LAND NUMBER ..... ----DATE-......_---------- <br /> -- ------- --------- -- <br /> ........................ <br /> .....�Ali ........ <br /> ADDITIONAL COMMENTS........ ------ <br /> .................­.......... .. .......... ----- --- ----------- -------­­--------------------------------- -------- --- ---------- <br /> --- - --- ------- -------------- ---------------------- ----------------- ------------ .......... <br /> -----------------------­.............. .I. ............. ...... <br /> --- ------------ -- ---- .................... -------------- ------------- <br /> --------------- ........­­------ ... ..... <br /> -----------------Date . <br /> Final by:............ . ........ . ........ ----- ---------_- <br /> EH.13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />