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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................................... ......... *.9-":3*. <br /> (Complete in Triplicate) Permit No.. <br /> --------•--------- --------- -------- -------- - <br /> Date Issued.4._..A_-7a, <br /> --------------- This Permit•Expire-s 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..--.b. .......... 5 � � G <br /> . .. ........ -------------- ---------- CENSUS TRACT..... <br /> Owner's Name.... �5._..--. 'Rem m��1 9'ss .�y� 1Z <br /> -------------------------- ----------Phone........-----.----.•---...---......... <br /> Address---...:Z t-24 .......f'k1C . <br /> Cit <br /> � iRCsf� <br /> ' 2`l 9�5? $13-`6 S� <br /> Contractor's Name......-- ---- �-�-•---- -� --�-------------- � -------•-----... �- ------..License #----�-�---.�.--•---...---..Phone.-�----=--�-�----��----...f- -� <br /> Installation will serve: ResidenceVotel <br /> Apartment House ❑ Commercial ❑ Trailer Court L]❑ Other_........... - - ---------------------- <br /> t <br /> Number of living units: ... .........Number of bedrooms-:::...Garbage Grinder-------- -..Lot Size.............I-A- <br /> . .... ..`' e------------...__..__.._ .. <br /> Water Supply: Public System and name -------- --------------- ...................... <br /> Private <br /> Character of soil to a depth of 3 feet: Sand-V 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,) y <br /> [ l Size oX ; k <br /> PACKAGE TREATMENT [ ] SEPTIC TANK �:--.��....--------,----------5-.........,-----------Liquid Depth.---•--------------------•- <br /> Capacity../_Z ..:------Type- �rt�`' -.Mat ialC....►;e ---._.:No. Compartments------�------------- <br /> Distance to nearest: Well......w�{..............•-.- -__`_ Foundation....�Ot. ...... ......Prop, Line:_5.1............... <br /> LEACHING LINE [ j No. of Lines .173.. ...................Length of each line...._120 ...--....--...... Total Length .....21_0.i......_....----------- <br /> 'D' Box.---I......Type Filter Material.... ..Depth Filter Mdterial...-..� ............................... <br /> Distance to nearest: Well-------........f. r -- �1 <br /> ..........Foundation ' Property Line_.._. - <br /> SEEPAGE PIT [ ] Depth.... .. .....Diameter---------------- ...Number...----------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth------- ---------------------------------------..........Rock Size.... ..........................----......-- ----.. <br /> Distance to nearest: Well............. . ....__-------------------Foundation---------- ----.--- - ...Prop1.Line.......___..------ -------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------- ....Date...... { <br /> Septic Tank (Specify Requirementsl -------- ------- - ----------------------------- -------------- -----------...................... --------- <br /> Disposal Field (Specify Requirements).-I.......--- --------------- ------- ------------------ ------------------------------ ----- ­------------- i <br /> --------- ------- ----- <br /> -------------- ---- ----- ------ -------- ------ .......................... --------- ----- - ........__--------------- <br /> (Draw existing and required addition on reverse side) 1 <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 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 ompensation laws of California." j <br /> Signed.--.--- - -- -- ........................... ........ ....Owner <br /> By......... .... ...... Title................................ <br /> (If other th owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..... .............. ._._DATE ....6.. 2 � <br /> DIVISION OF LAND NUMBER------------------ - ......------......-- ---.-.DATE............ _V- <br /> 00; <br /> ADDITIONALCOMMENTS---------------- ----- ------__.......--------............................ ----------------------------------- L --- ...... - b�. ...... .. <br /> .......................... ................. ................. ................................... <br /> j." <br /> ..................... ­---- <br /> ------ <br /> --------------------------------------------------__ .............................................................................................. ----------------- ............... . <br /> Final Insp cflon b Date.................... ...... --... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2!677 REV. 7176 3M <br />