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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ,' <br /> Permit No.... .. --------------- <br /> -------------------------- <br /> - - <br /> IComplete in Triplicate) --- <br /> ---------------------------- ------- --------------- - <br /> 31�? <br /> ..........•••-•-•..---...------._....................... This Permit Expires 1 Year From Date Issued 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/LOCATI N....--- --- ! I _ ......t ,-------------------------------------------------------CENSUS TRACT--------------------- <br /> ------ <br /> Owner's Name....... Q.�Pi` a....� Phone <br /> Address............... .. .... . Ci Zi - <br /> /�- ry P r.... / <br /> 106 <br /> Contractor's Name............. .`..... _.License #... ± .z74Y.Phane... - -� `--+.--._. <br /> Installation will serve: Residence ❑ Apartment House ❑ Coyne�+ercial ❑ Trailer Court ❑ <br /> Motel ❑ Other...7-.�4-.'...�/.t►.J1 1�✓. <br /> Number of living units:-----_--------Number of bedrooms............Garbage Grinder.-----------Lot Size_- to..... ------ ................. <br /> Water Supply: Public System and name.. ---- --• -------------- -------------------------------------- -PrivateAKr <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.....3X1i..K_ -.---------Liquid Depth---Z�....------ <br /> Capacity.100---------Type HM,_.V Material.84/" .,.........:No. Compartments..---- :---- ------ -----`� <br /> .�..-- <br /> Distance to nearest: Well-.---.-.-.. ..........................Foundation..../.10- -...........Prop. Line-.. --. -.-..-•..-- . <br /> LINE [�' No. of Lines _........l.._.............Length of each line..... O. -.... -....----Total Length ..._-.. d..__-.--..-_-.._._...� <br /> LEACHING - �� <br /> D' Box............Type Filter Material ! �.�.Depth Filter Material-.-,.-.-/-.g. ..............._.... __.__..%.__...... <br /> Distance to nearest: Well....... __._.. .-.-_.Foundation----40--------------...Property Line...- -�+'4+.......,,�� <br /> S66PA"t PIT [AIr Depth._.f.Q__....Diameter. ---Number---/------------------------ .� RoRock Filled Yes [gO' No [ <br /> l � <br /> SWater Table Depth----- ---?J6-•------- --- -- -•--- _.----.........Rock Size. `---------------------------- <br /> Distance <br /> --•-•------------ - -------Distance to nearest: Well-------- -----------------------Foundation....-� .-- ----. -. Prop. Line..1T........... <br /> .--.r <br /> REPAIR/ADDITION {Prev. Sanitation Permit#---------------------------------------------------Da#e................-.._-_._--__..---.----------1 <br /> 01- <br /> Septic <br /> LSeptic Tank (Specify Requirements)--------...................... -- ---...----- ------- ...... <br /> Disposal Field (Specify Requirements)-------------------- <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 =tark an s ompe sation laws of California." <br /> Signed....... - .... Owner <br /> By............... .t �_ .w4-4..Title....----• - +► -- --- <br /> (If other than owner) <br /> FOR D P T USE ONLY <br /> APPLICATION ACCEPTED BY--------------..:........ ---------------------------- .DATE --------- -lq <br /> DIVISION OF LAND NUMBER.-- ---- ....................................... .......DATE--...............-........... <br /> ADDITIONAL COMMENTS.-------- .................... -------------------_---- <br /> ---------------------------------------- <br /> •------------------- -------- -- :.-.. .-.. <br /> Final tnspeciion by:.....--- --Date. ---- -- <br /> --------------------------------------------- <br /> �..�(. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F65 21677 REV, 7/76 3M <br />