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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------ <br /> r (Complete in Triplicate) Permit No,.�. `.K.1..... <br /> ------•--------------- -- ---- <br /> Date Issued._ .-.�.I.-? <br /> s •........................... ...............-.. � This Permit Expires 1 Year From Date Issued <br /> 3 <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> s This application is made in complionc'e...wiith Lunty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATITI�ON...... ... ... . .. :......4F7---- ..........------.CENSUS TRACt_...-.-. - --=-- <br /> Owner's Name.-.. . !!° �`�1✓�e '�. ..: - - Phone_ .71....x.1, ... .. <br /> Phone- <br /> Address.--: 7`Po2�-•.-..64IES77-G J� City.-- � D' _ZiP <br /> a- ... <br /> Contractor's Name. >.A .�.� License # Zy�rry $ _Phone---61 <br /> 3'.C" ... <br /> Installation will serve: Residence] Apartment House E] Commercial F-1Trailer Court F]i Motel ❑ Other------ -------------- --------_----------- <br /> Number of living units:-.--.../- --Number of bedrooms..c....Garbage Grinder_.,..&31.ot Size-----`6,s—X. -------- - .... <br /> Water Supply: Public System andname. -..ill t G�,:............................... --------------- ------ ----------------- --------------- ------Private E]Character of soil to a depth of 3 feet: SandK Silt.❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material _ _.-. ._.Ef yes, type....------- .............. (6N <br /> (Plot plan, showing size of lot, location of system in relation to welts, buildings, etc. must be placed an reverse side.) <br /> r� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] t V <br /> PACKAGE TREATMENT SEPTIC TANK I X....f�. - --- Il <br /> [ ) [ ) Size...... ......... ---------------.-Liquid Depth.-- <br /> f UO ...T e.-n_RLC`N51 Material----Cemenil---_- -No. Compartments........:... ........... <br /> Capacity - �--2-- -...--- YP ii`........... ...... <br /> � i 1 � i <br /> Distance to nearest: Well...............�0.........................Foundation.......... ........Prop. Line ... ----...---... <br /> LEACHING LINT: [ j No. of Lines F_.__3--------------------Length of each line_---- --------Total Length . .._2-. .... ........... <br /> ' -J."1-_.-..Depth G .1 <br /> 'Q' Box-..--...'...Type Filter Material-- .. . Filter Material....-.--J..�-----.....---------•.•------------------------- - <br /> Distanceto nearest: Well--- t...........Foundation.....--.u_F_..._._......Property Line_.._. ------ _............. . <br /> SEEPAGE= PIT [ j Depth . ... .Diameter--------------------Number----------.--------------------- Rock Filled Yes ❑ No <br /> Water Table Depth-------------- -­---------------------------Rock Size.- .......--------------------------•....... <br /> Distance to nearest. Well-------------------------- Foundation.....- ......Prop. Line----.-..--..--------------- <br /> E REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------- -------- Date-.j.._- :.--.-.-----........F <br /> MSeptic Tank {Specify Requirements)----------------------------- ;- -----=•------- ------ <br /> Disposal Field {Specify Requirements)............ x - . - ";f <br /> �_ ----------_------- -- <br /> �f -f <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 bet ' <br /> 04. <br /> a su e o Wo an's Csompensation laws of California." <br /> Signed C.C. -. .......... ....--- ---Owner 4 1\ <br /> { BY------ ----------------------- --------......... .............Title---- --.......---6=-....---------. ------- ----- ------------ <br /> (If other than owner) , <br /> OR APARTMENTILISR ONLY <br /> APPLICATION ACCEPTED BY /L l?!t":°` DATE <br /> DIVISION OF LAND NUMBER.-- ' ----------------- -------- DATE... <br /> ADDITIONAL COMMENTS- ---------------------- ----------------------------------- -------- ..------.- <br /> ................••-•------.....---------------------------. -------------• -• -----•-- --.---------------- ----------------------- --- --- ...........-.. <br /> .. ..------. -- <br /> - J <br /> Final Inspection by: - ------------Date..----- ---- ..... . <br /> ---- ---------- <br /> EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> { <br />