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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT rq <br /> ----------......____------------------ ......­11----- - -- --- ------------ Permit Np/4 — <br /> - (Complete in Triplicate) '--- <br /> �\ Date Issued- a `7 <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ®...._. ..65--- --------------- ---- ------_-----..CENSUS TRACT..............•--- <br /> Owner's Name.... - xd - Phone..... <br /> _..._ •. -•--....---- •-----------. <br /> Address...._ 1.� - ------- --------- --- CitY.........__-....... ...... -- -...._.Zip--......._...-- <br /> Contractor's Name.----- ./ U.z -p-�.. ........ ......License #_9.(�- L-7 --- -Phone... - ® f-----. <br /> `�f". <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ inn <br /> Motel f-1Other.. . ........ . . ......................... vl <br /> Number of living units:........ ._._Number of bedrooms__.. . Garbage Grinder.....-------Lot Size........ ...... ...................... -. - - <br /> Water Supply: Public System and name_ ..... ---- ..._.. - -----•-•........................ - -..----------_------_----------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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size --- ------.----Liquid Depth..-..._......._....._._ <br /> Capacity./ ----Type----;,1_1:---- ---...Material_4a'.­4-----------_No. Compartments-----'a�- <br /> Distance to nearest: Well.......40.0... ........... .........Foundation.....f-l). ---. . . .. Prop. Line......��................... <br /> LEACHING LINE [ J No. of Lines _-p� .....................Length of each line._r*............ .. Total Length .. 0 <br /> ♦0 <br /> 'D' Box4....... Type Filter Material----/_-__Depth Filter Material.—l._. ------..-------- ..........--.----.----. <br /> Distance to nearest: Well-_119P... .... ......Foundation-_-/4P.O.___.___-----..Property Line..... ............................. <br /> Depth;3AIPX lq%iameter------------------..-Number-------91.._.___.___.......-. Rock Filled Yes A No❑ <br /> f <br /> Water Table Depth--------------------------- --- - .................Rock Size...../_ _.. <br /> Distance to nearest: Well._ .-Q__---- --------------------Foundation.----/.6e7--_. ...._.Prop. Line--,V'--.----- --.-- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...._-----------------_....__..._ ..-............Date.-..._..._-_._..__.----------------- --------) <br /> Septic Tank (Specify Requirements)_...._--- ....................................... --------- <br /> Disposal Field (Specify Requirements)----------.... -_----............ -----------------------•--­.- ---.------ <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 /> "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 /> BY-------- � �(/� �Lt- �? - Title.. - - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..-----....r64O, _-------------------------------- -DATE .✓`./.2.. <br /> DIVISION OF LAND NUMBER--------- ---- ---------- ---_-------_- -_ ----•----------------------------- DATE.--------- ... ------ <br /> ADDITIONAL COMMENTS__.................. . -- --- -- - -- <br /> --------------- ---------- -_. -------...----- ------------- ----- ......................... ..........-.._............ ------------------•-- ......... ................... ._....._.._..... <br /> ------------------------ --------- - -------_....._.. _.-- -- -- ----......-•----.... ....... ......................... ----------- ........................I........... - ---- -- - <br /> -------- ------------------ <br /> - - -- - - -... - ------ --- --- <br /> Final <br /> ---- -- --- <br /> Final Inspection by:---- -----•- ----------------------------------Date--- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />