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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------- -------- - -- Permit No..� --S�+i-'-7 <br /> - ------------------ <br /> (Complete in Triplicate} <br /> A ) Date Issued_4'.; G".?af <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issuer! <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 /> �S� W A/ <br /> JOB ADDRESS/LOCy---„ r -------- C - ---- - CENSUS TRACT----- �-� , <br /> Owner's Name 'L_----- -- -- '---------------- ---- Phone-J6 �� `�------ <br /> Address �_ C lUcity-- Zip �5- <br /> ._ <br /> �G, �. o s a4p-3r33 <br /> Contractor's Name. � --- ---------- ----- -.--License #---------7--------------Phone--`----------------------- -- <br /> Installation.will serve: Residence E�J-�Apartment House.❑ Commercial ❑ Trailer Court ❑ i <br /> Motel ❑ Other---. --- i--- <br /> Number of living units:--,. ------Number of bedrooms_._7-__.Garbage Grinder.__ _-__Lot Size---- -------------- -------------------------=---- <br /> Water Supply: Public System 'and.name----:. :_ ----Private.�E� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ -Clay`❑ Peat ❑ Sandy Loam,� Clay Loam E] <br /> . Fill Material_:____. ' <br /> f Hardpan ❑ Adobe ❑ If yes, type___'---------------------------- <br /> {Plot plan, showing size of lot, location of system in relation to wellsbuildings, etc. must be placed on reverse side.} <br /> NEW INSTALLATION: (No`septic tank or seepage pit permitted if`pubhc sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [�}� Size-----CP COX �a—j______-___Liquid Depth --------------- <br /> ---------- <br /> Capacity-/(op <br /> r_.-___ <br /> -- - ----- ------------------ - ----- <br /> n <br /> Ca acit 0� _-Material°;( off No. Compartments__._____z-_______________`__ <br /> - � r pp /- Prop. Line----��`- <br /> .3 - - 1-._t-Foundation <br /> LEACHING LINE, [`;] Not ofcLmes�earest: WeIL=--,� _ � _ <br /> Leng'th,of,each Ime------------------------ <br /> 'D' <br /> . __y ,,_P_ . _.Total Length _ _�'�p f <br /> ' Y__4/rT e Filter Ma al__�`�Xl�_� a tlirF.ilte r <br /> • + 'D' Box_ r Sa±er}.al.---.__-------------- ---- - ------- <br /> r J <br /> Distance to nearest. Well__ ______________________Foundation-_a2--_._-._____-____.__.Property Line-._-_S__-.__---_.___.--.___ <br /> SEEPAGE PIT [ ] Depth-_ 5-'._-_Diameter. _._7;____-_._.-Number/ -3_'_ .-----------_ Rock Filled .Yes �.� Na ❑ <br /> Water Table Depth �Ca-----------------------------__ +__'Rock,fS�ze_-__�_u-X <br /> -- ------ _._. <br /> arest. Well________________________________ ____Foundation _ 5 Prop. Line <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--'--------------------------------------- --`'------ <br /> r . r -----------------ia1 te-----=- ---=---=- <br /> ----- ----------:-`------------ <br /> Se tic Tank (SpecifyRequirements)_ --_-- ------- - --- ------------------- -._ ]- -- - <br /> - <br /> slDisposalField (Specify Requirement - -----'--------------- -------------------- ---------------------------------------------------------------I--------------------------------- ----- <br /> --- <br /> '. <br /> - : <br /> ,1 <br /> (DV6w existing and requiredadaition.onlreverse,side) <br /> hereby certify that I have prepared this application and that4e work :will.e 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 /> "I certify that in the performance of the-work-f&--Which this permit is issued f"sh1dllnoF employ any person in such manneras <br /> to become subject to Workman's Compensation laws of California.'.' ' <br /> Signed----- ----- ------ -- i-----=- ---- --'-- -�-fOwner ' <br /> BY - ------------------------------ : Title. V_L %L.L. <br /> (If other than owne'r) <br /> t FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED. BY-- .-_-- ---1Z _DATE.___ -_2_�'--.---C�----- <br /> DIVISION OF LAND NUMBER------------------------------------ -----_ -------------------------------------------------------- <br /> -_. - .-- -------------- ------ <br /> DATE--------=---- - --------=----------------------- <br /> ADDITIONAL COMMENTS ----------------------- - ------ ---------------- ----------------------------- <br /> • 9 <br /> -------------------------------------------------------------------`-------------------------------------------------------------- -------------- <br /> ------------------------------------------------------------- ------------------- _----------------- <br /> ----�--------------- ------------------------ ---"- --- - - - - ---- --- ------ F <br /> Final Inspection b == - - --- --` L�' ----- -------------------- Date <br /> ------------ ---- ----------- <br /> P Y:----------- _ <br /> EH 13 24 SAN JOAQUI LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />